LIBRARY OF CONGRESS, 
Shelf. *£.&* 



UNITED STATES OF AMERICA. 



GONORRHOEA 



BEING THE TRANSLATION OF 



BLENORRHCEA 
OF THE SEXUAL ORGANS 

AND ITS COMPLICATIONS 



BY 

Dr. ERNEST 'FINGER 

Docent at the University of Vienna 



THIRD REVISED AND ENLARGED EDITION 



With Seven Full-page Plates in Colors and Thirty-six Wood 
Engravings in the Text 



K APR 7 1894* 






NEW YORK 

WILLIAM WOOD & COMPANY 

1894 






Copyright, 1894, 
BY WILLIAM WOOD & COMPANY 



PRESS OF 

THE PUBLISHERS' PRINTING COMPANY 

132-136 W. FOURTEENTH ST. 

' NEW YORK 



PREFACE TO THE THIRD EDITION. 



rT^HE favorable reception which the first two editions of my 
-*- monograph received from the medical profession is a 
sufficient reason for avoiding material changes in the present 
edition of the work. I have merely attempted to add the ex- 
periences and advances which have been made since the ap- 
pearance of the second edition. During the last few years 
much attention has been devoted to the subject of gonorrhoea, 
and our knowledge in this direction has been considerably 
enlarged. The possibility of more ready culture of the 
gonococcus, and greater precision in the question of mixed 
infections, constitute important achievements. On the other 
hand, I have been able, through the great kindness of Pro- 
fessor Weichselbaum, to make the first systematic anatomi- 
cal examinations of chronic urethritis. These points form 
the principal changes and additions to be found in the pres- 
ent edition. The two additional plates (VI and VII) are 
intended to illustrate anatomical conditions. I have also 
endeavored in other ways to keep the work up to the 
modern standpoint. Ma}' this edition meet with the same 
good fortune as its predecessors. 

The Author. 
Vienna, June, 1893. 



CONTENTS. 



PAGE 

History, ...... 1 

Etiology, & 



CHAPTER I. 

BLENORRHCEA IN THE MALE AND ITS COMPLICATIONS. 

Urethral Blenorrhoea, . . . . 23 

Anatomical and Physiological Remarks, 23 



CHAPTER II. 



ACUTE URETHRITIS. 



Infection, 41 

Symptomatology, . ... . . . . . . . .45 

Acute Anterior Urethritis, 46 

Posterior Acute Urethritis, ......... 62. 

Diagnosis and Differential Diagnosis, ..... e . 73 

Prognosis, ,79 

Anatomy, 81 

Treatment, SO 

Oversight of the Remedies, ......... 97 

Local Remedies, 105 

Methods, 117 

Treatment of Anterior Urethritis, 119 

Treatment of Acute Posterior Urethritis, ...... 132 



CHAPTER III. 

CHRONIC URETHRITIS. 

Etiology, 138 

Symptomatology, 141 

Chronic Anterior Urethritis, 143 

Chronic Posterior Urethritis, ........ 145 

Secretion, 149 

The Infectiousness of Chronic Gonorrhoea, 154 

v 



vi Contents. 

PAGE 

Localization, 155 

Pathological Anatomy, 169 

Pars Anterior, 171 

Pars Posterior, .... 175 

Diagnosis and Differential Diagnosis, 181 

Prognosis, 188 

Treatment, 189 



CHAPTER IV. 

COMPLICATIONS OF BLENORRHCEA IN THE MALE. 

General Remarks, 204 

Balanitis, 207 

Etiology, 207 

Symptomatology, 209 

Diagnosis and Differential Diagnosis, 212 

Treatment, 214 

Follicular and Cavernous Infiltration and Abscesses, .... 215 

Symptomatology, 215 

Treatment, 221 

Inflammation of Cowper's Glands, 222 

General Remarks, 222 

Symptomatology, 223 

Diagnosis and Differential Diagnosis, ...... 225 

Prognosis, Treatment, 226 

Inflammation of the Prostate, 226 

General Remarks 226 

Symptomatology, 227 

Chronic Prostatitis, 232 

Pathological Anatomy, 232 

Diagnosis and Prognosis, 233 

Treatment, 234 

Inflammation of the Epididymis, 236 

General Remarks, 236 

Symptomatology, 240 

Pathological Anatomy, 249 

Diagnosis, Prognosis, 252 

Treatment, 252 

Inflammation of the Seminal Vesicles, 258 

Inflammation of the Bladder, 259 

General Remarks, 259 

Symptomatology, 261 

Diagnosis and Differential Diagnosis, 265 

Pathological Anatomy, 266 

Prognosis, Treatment, 267 

Inflammation of the Renal Pelvis and Kidney, 270 



Contents. vii 
CHAPTER V. 

BLENORRHCEA IN THE FEMALE. 

PAGE 

General Remarks, 271 

Urethritis, 277 

General Remarks, 277 

Symptomatology, 277 

Pathological Anatomy, 280 

Diagnosis and Prognosis, 281 

Treatment, 281 

Vaginitis, 282 

General Remarks, 282 

Symptomatology 283 

Diagnosis and Prognosis, 285 

Treatment, 286 

CHAPTER VI. 

COMPLICATIONS OF BLENORRHCEA IN THE FEMALE. 

Vulvitis, 290 

General Remarks, 290 

Symptomatology, 290 

Diagnosis, 292 

Treatment, 292 

Inflammation of Bartholin's Glands, 293 

General Remarks, 293 

Acute Bartholinitis, 294 

Symptomatology, 294 

Treatment, 295 

Chronic Bartholinitis, 295 

Treatment, 297 

Inflammation of the Uterus and its Appendages, .... 297 

CHAPTER VII. 

COMPLICATIONS OF BLENORRHCEA IN BOTH SEXES. 

Gonorrhoeal Rheumatism, 302 

General Remarks, 302 

Etiology, 302 

Symptomatology 304 

Pathological Anatomy, . . - 309 

Diagnosis and Prognosis, 311 

Treatment, 312 

Blenorrhagic Endocarditis, 312 

Blenorrhagic Exanthemata, 315 

Blenorrhagic Ophthalmia, 315 

Blenorrhagic Adenitis, 316 



BLENORRHCEA OF THE SEXUAL 
ORGANS. 



HISTOET. 



Although the views concerning the antiquity, development 
and origin of constitutional syphilis are very divergent, and 
the documents and data which testify to the knowledge of 
this plague in the time of the Jews, Romans and Greeks are 
so scanty and obscure, that we must strongly doubt whether 
this mooted question will ever be definitely settled, neverthe- 
less we may maintain with positiveness that blenorrhoic dis- 
ease of the genitalia are as old as the human race. At all 
events they can be traced back historically almost as far as 
the history of man, and appear at the same time as the latter 
out of the mythical obscurity of legends and tradition. We 
find at least, among the cultivated nations of antiquity as well 
as of the Middle Ages, in part appropriate descriptions of the 
symptoms of blenorrhagic affections, in part unmistakeable 
indications that the etiology, the contagious character of the 
disease, had not escaped observation. This original clearness 
and correct knowledge gave way to confusion when, almost 
coincidently with the discovery of America, syphilis traversed 
Europe as a pandemic, — whether as a new disease may be 
doubted, but at all events with hitherto unknown virulence. 
The relatively mild and harmless symptoms of blenorrhcea 
were of no importance compared with the severe manifesta- 
tions of syphilis, the majority of which also started from the 
sexual organs, and thus blenorrhcea sank into oblivion, at least 
among medical writers. And in the same measure that the 
violence and malignancy of syphilis gradually diminished, 



2 BlenorrJicea of the Sexual Organs. 

bienorrhoea again became the subject of observation and study; 
the knowledge that both diseases were localized generally in 
the genitalia, often occurred together and were both conta- 
gious, led to their being grouped together, and to blenorrhoea 
being regarded as a symptom of syphilis. Although this view 
did not remain unopposed, it prevailed for a long time, and 
not until the middle of the eighteenth century did the number 
of voices which advocated the separation of blenorrhoea from 
syphilis become greater and their importance more and more 
considerable. Finally, the separation became definitive in the 
thirties of the present century. 

Thus we can distinguish three periods in the interesting 
history of blenorrhoea, the first period — until the occurrence of 
S3 T philis — in which blenorrhoea stood alone; the second — until 
1830 — which represents the period of confusion; the third 
period, beginning with 1830, and which continues to the present 
time. 

First Period: until the occurrence of Syphilis as a Pan- 
demic. — Numerous texts prove that blenorrhoea was known 
to the civilized nations of antiquity, and that it was also re- 
garded by them as contagious. 

Thus the Jews knew blenorrhoea very accurately, and in 
Leviticus hi. 15, Moses not alone gives a description, but also 
sanitary and police regulations which testify to accurate 
knowledge of the disease. 

Whether the words used concerning David's disease in Lev., 
Chap, xv., refer to this affection must remain in doubt. 

Maimonides describes blenorrhoea clearly. He says: the 
fluid escapes without erection and without a feeling of pleasure ; 
the appearance is similar to that of barley dough in water, 
which is dissolved, or coagulated albumen, and is the result of 
the internal disease; it is also essentially different from the 
seminal fluid and mucus, the latter being more homogeneous. 
Maimonides mentions seven causes of the disease, including 
amorousness and excesses. 

Blenorrhoea was also well known to the Greeks and Romans. 
Thus, Herodotus relates that the Scythians, who had violated 
the shrine of Yenus-Urania, were attacked by the morbus 
femineus of the vouffo^Xeta. Hippocrates speaks of the sensa- 
tion of burning during micturition and of the white discharge 
of women. Oelsus mentions ulcers in the urethra and the dis- 



Blenorrhcea of the Sexual Organs. 3 

charge of bloody, purulent matter from the canal. Corre- 
sponding- texts are found in Juvenal, Martial, Dioscorides, 
Scrihonius Largus, Sextus Placidus, Pliny and Galen. Galen, 
in particular, separates satyriasis, the escape of semen from 
the erect penis, from gonorrhoea, the escape of semen without 
erection. Aretaeus distinguishes vaginal blenorrhcea from 
fluor, and Marcellus Empyricus, Physician to the Emperor 
Theodosius, mentions remedies. 

The statements of writers of the Middle Ages concerning 
blenorrhcea are more numerous and detailed, above all those 
of the Arabists. Thus, we read in Johannes Mesue, who lived 
in the tenth or eleventh century: Si vero in via et ductu 
urince ulcer a sunt, cognoscuntur ex dolor e magis in urince 
egressione et sanie egrediente ante urinam. Ulcera virgce 
et apostemata sunt proportionalia ulceribus et apostemali- 
bus testium. Haly Abbas speaks of an urethritis which is ac- 
companied by a white discharge and pain in urination. Phages 
discusses burning during micturition. He recommends bolus 
armena, dragon's blood and injections in purulent discharges 
from the urethra. Serapion also discusses blenorrhcea, ulcers 
in the urethra, which provoke pain and purulent discharge. He 
defines gonorrhoea as increased involuntary discharge of semen 
and recommends hemp seeds against it. He also gives a good 
description of the suppurations of the female genitalia, which 
result from excessive coitus. Ebn Sina describes clap as fol- 
lows : Sentitur acuitas et mordicatio in egressione et quan- 
doque est cum ea ardor urince, et est color ejus ad citrin- 
itatem declivis. In the eleventh century Abulcasem used 
injections of a mixture of vinegar and water in gonorrhoea. 

In the other writers of the Middle Ages we also find de- 
scriptions of blenorrhcea, as well as some police ordinances for 
the prevention of its spread by prostitutes. Gariopontus 
discusses gonorrhoea, and Michael Scotus, physician to the 
Emperor Frederick I., recognizes its infectious nature. Ro- 
gerius, a physician of the twelfth century, treats of reu- 
matisatio virgce: Quando reumatisant humor es ad canales 
virgce, et faciunt ibi pustulas et apostemata, si fiat de 
calida causa, cognoscitur per calorem, per punctionem et 
arsuras, per rubor em et inflammationem membri. Si fiat 
de causa frigida, cognoscitur per remotionem punctionum, 
et mordicationem et per exclusionem ruboris; in utraque 



4 Blenorrhcea of the Sexual Organs. 

causa difficultas mingendi. Lanfrancus, a pupil of "Wil- 
liam de Saliceto and a distinguished physician of the 13th 
century, speaks de apostematibus virgce in the following 
terms: Aliquando repletur virga ventositate grossa, ipsam 
cum dolor e nimis extendente, cum autem cessat materice 
cursus, si vero apostema testiculi induretur. Constantinus 
Africanus recommends remedies against strangury. Joannes 
Ardern, a physician of the 14th century, recommends sedative 
injections against blenorrhoea. Guido de Cauliaco speaks, in 
his Surgery of burning and disease of the penis from intercourse 
with a diseased woman. Joannes de Gaddesden recognized ure- 
thritis and epididymitis, he was also acquainted with vaginitis. 
Similar statements are found in Yalescus de Taranta, Guliel- 
mus Vareguana, Magninus, Joannes Arculanus, Joannes de 
Tornamira, Antonio Cermisone and many others, which leave 
no doubt that blenorrhcea was very well known, was regarded 
as contagious, and treated with local remedies. That the con- 
tagious character of blenorrhoea was generally recognized is 
shown above all by some police ordinances which have come 
down to us. Thus, Beckett reports an ordinance of the Bishop 
of Winchester for the houses of prostitution of Southwark, a 
suburb of London, which, eighteen in number, are said to have 
been under the supervision of this Bishop. This ordinance 
dates back to the year 1162. One of its articles reads as fol- 
lows: De his qui custodiant mulieres habentes nefandam 
infirmatatem, and begins thus: "That no Stewholder keep 
noo woman wythin his hous, that hath any sycknesse of Bren- 
ning," or, as is said in a similar ordinance of this Bishop, " the 
perilous infirmity of burning." 

An ordinance concerning the establishment of a house of 
prostitution in Avignon, which is attributed to Johanna I., 
Queen of both Sicilies, is dated August 8th, 1347. The fourth 
article of this ordinance reads : " The Queen commands that 
the superintendent and a surgeon appointed by the authorities 
examine, every Saturday, all the whores in the house of pros- 
titution. And if one is found, who has contracted a disease 
from coitus, she shall be separated from the rest and live 
apart, in order that she may not distribute her favors, and 
may thus be prevented from conveying disease to the youth." 

All these quotations show sufficiently that blenorrhoea 
existed in antiquity and the Middle Ages, that its nature and 



Blenorrhoea of the Sexual Organs. 5 

contagious character were recognized, and that prophylactic 
and therapeutic measures against it were adopted. Then 
towards the end of the 15th century syphilis appeared upon the 
scene, and spread rapidly with hitherto unobserved intensity. 
What wonder that the attention of the medical public was 
directed exclusively to the new and malignant disease, that 
blenorrhcea sank into comparative oblivion and that thus begins 

The Second Period, that of Confusion. — It would be going 
too far to assume that the newly developed syphilis had cast 
gonorrhoea into complete oblivion. This is not true. It was 
merely that the new and interesting disease diverted attention 
and study from the old and known, but without causing it to be 
forgotten. Thus, the contemporaries of the first great epide- 
mic of syphilis speak incidentally of blenorrhoea as a disease 
long known, or they do not mention it at all in the treatises 
devoted to the new affection. Thus, Grunpeck (1496), Fra- 
castor (1530), Mattheoli (1536), Massa (1536), do not mention 
gonorrhoea; Johannes de Vigo (1513) in his Surgery, in the chap- 
ter de auxiliis cegritudinum virgce — speaks in detail of blenor- 
rhoea and its treatment. Alexander Benedictus (1510) discus- 
ses syphilis and clap separately, as does Marcellus Cumanus, 
a military surgeon of the Venetian Army during the period of 
the first epidemic (1495). Jaques de Bethencourt (1527) relates 
the history of a chronic blenorrhoea. Paracelsus (1530) also 
recognized blenorrhoea, and mentions it as a possible com- 
plication of syphilis, like dropsy, podagra, paralysis, icterus 
and catarrh. In England Simon Fish (1530), Andrew Boord 
(1546), Michael Wood and William Bulleyn (1560) describe 
blenorrhoea, particularly in women, as a distinct disease, sepa- 
rate from syphilis. It seems to have been very widespread 
among prostitutes. 

In opposition to these views Musa Brassavolus (1553) ap- 
pears to have been the first to regard blenorrhoea as a S3'mp- 
tom of syphilis, and, like the latter, as a new disease, whose 
origin dates to the year 1531. Nevertheless Brassavolus did 
not believe that symptoms of syphilis could develop from 
gonorrhoea. Gabriel Fallopius, the pupil of Brassavolus, co- 
incides in this opinion of the syphilitic character of gonorrhoea. 
In a treatise published in 1563 we read: "the final symp- 
tom is Gallic gonorrhoea. Thirty years may elapse before 
this discharge begins." Tomitanus also accedes to the opinion 



6 Blenorrhcea of the Sexual Organs. 

that blenorrhcea is a symptom of syphilis, and this belief pre- 
vailed for nearly two centuries. The results of this view were 
serious. Every clap was regarded as of equal importance to 
syphilis, and subjected to the most vigorous treatment with 
mercury, guaiac and sarsparilla. A few warning- voices were 
raised, for example P. Haschard (1554). 

It was not until the beginning of the 18th century that the 
opposition began, at first timidly,then more boldly, and thus the 
third period in the history of blenorrhcea was inaugurated. 
Cockburn's (1715) statement that blenorrhcea was not usually 
followed by symptoms of syphilis, remained unnoticed. This is 
also true of Boerhaave's (1753) admission. Balfour (1767) asks 
very timidly : Nonnie potius suspicandum est, longe diver sam 
esse materiam, quam lueni paruit, ab ea, ex qua gonorrhoea 
efficitur. Hales (1770) was the first to advocate the com- 
plete separation of the gonorrhoea and chancre virus, and 
Ellis (1771) made a large step in advance by making experi- 
ments subservient to his views. He also distinguishes the 
virus of syphilis from that of blenorrhcea. He says: "It 
seems most probable that there is something in the venereal 
particles of matter, in a gonorrhoea, which is very different 
in its nature and figure from that of the pox. * * * * 
The virus of the gonorrhoea, if exposed to any part denudated 
of its skin, will not form a chancre, but will heal with a little 
styptic wash, and any soft dressing, as I have observed in 
several cases." Bayford (1773) opposes Ellis' views because 
he never succeeded, with the aid of the microscope, in detect- 
ing any difference between the pus of clap and chancre. Tode 
(1774) combatted the identity of the virus of clap and syphilis, 
and likewise Duncan (1777), who adduces as an argument the 
fact that the inhabitants of Otahiti were acquainted with 
syphilis long before clap was imported among them. Harrison 
(1781) and Swediaur (1784), also employed the experimental 
method, but were led by their investigations to support the 
identity of both viruses. And thus the syphilidologists at the 
end of the 18th century were divided into two camps — the 
identists who believed in the identity of the virus of clap and 
syphilis, and their opponents, the dualists. Once again the 
scale turned in favor of the identists. John Hunter entered 
the arena. There are few names so popular in our specialty, 
and when Kicord and Sigmund are mentioned to-day, Hunter 



BlenorrJioea of the Sexual Organs. y 

is usually added as the third. Unfortunately with but slight 
justification. Not that we deny to Hunter ardent, even pas- 
sionate devotion to his profession, great gifts and scientific 
earnestness, but it is rare that such qualities have produced 
poorer fruits, and have done less to forward a science than 
in the case of Hunter, very much to the disadvantage of the 
beginning freer development of our specialty. With the object 
of checking the battle between the identists and non-identists, 
and of getting at the truth of the matter, Hunter performed 
(May, 1767) upon himself, it is said, the following inoculation 
experiment, which proved so momentous to our science. One 
Friday, as he relates, he inoculated the gonorrhceal pus into 
the glans and prepuce by means of two incisions with a lancet. 
Both incisions were converted — that on the prepuce more 
rapidly, that on the glans more slowly — into pustules and 
superficial ulcerations, which were accompanied by inflamma- 
tory symptoms. Both spots were then cauterized repeatedly 
and slowly healed. During recovery swelling of the inguinal 
glands occurred, about three months later an ulcer appeared 
upon the tonsils, and three months later a copper-colored 
pustular eruption, i.e., symptoms which could certainly be 
attributed to syphilis. Despite all previous experience this ex- 
periment was sufficient for the investigator, who was very 
quick in arriving at conclusions, to draw the inference that 
gonorrhceal pus may produce chancre. This single experiment 
involved a standstill — yes, a retrogression of more than 
sixty years — since even the shallowest follower of Hunter felt 
himself justified, relying upon Hunter's authority, his inocula- 
tion experiment and "personal experience," in breaking a 
lance for the unitist theory. It is true that Hunter distin- 
guished a venereal from a simple clap, which could develop 
from other causes, or even spontaneously, but he did not 
clearly describe their differential diagnostic signs. And so 
began anew the struggle between the unitists and dualists, 
the former maintaining, through Hunter, the upper hand. 
Howard's (i 787) opposition to Hunter's doctrines passed un- 
noticed. If the dualists claimed that constitutional syph- 
ilis never develops after clap — that the virus of clap never 
produces chancre, that of chancre never produces clap — that 
mercury cures syphilis but not clap — that clap and syphilis 
developed at entirely different periods — that clap generally 



8 Blenorrhoea of the Sexual Organs. 

recovers spontaneously, syphilis never without the aid of art, 
— the answer given by the unitists was always the same. It 
is true, they said, that syphilis develops after a neglected 
clap, though not so often as after chancre — it is claimed that 
chancre virus does not produce clap and vice versa, but ex- 
perience proves the contrary; that mercury is not necessary 
to the cure of gonorrhoea is owing to the fact that the clap 
virus in the urethra is outside of the circulation, and its ab- 
sorption is made difficult by the increased secretion of mucus; 
however, many gleets are not curable without mercury. 
Buboes, like clap, also existed prior to syphilis, and are never- 
theless undoubtedly syphilitic in character. 

Benjamin Bell (1794) was the first who, based upon a series 
of experiments, secured a hearing for his opposing views. 
Starting from the theory of the unitists that the same virus 
produces ulcers upon the glans penis and clap upon the mucous 
membrane of the urethra, he raises the following objections : 
a. Chancre should be more common than clap, since the outer 
surface of the glans is more exposed to infection than the 
mucous membrane of the urethra, b. Chancre should always 
be complicated with clap and vice versa, since the pus from 
ulcers of the glans always passes into the urethra, the pus of 
clap always reaches the glans. c. The pus from the urethra 
is often so acrid that it excoriates the glans and prepuce but 
does not cause ulceration, d. Even the smallest chancre 
produces general infection, e. Clap and the erosions of the 
glans produced thereby do not give rise to syphilis. /. 
Chancre pus placed in wounds produces the venereal disease, 
the pus of clap does not, as the inoculation of two physicians 
with gonorrhoeal pus showed. It would also be necessary to 
assume that a person who merely had a chancre conveys clap 
to another, and vice versa. Clap is a discharge of pus-like 
material from the urethra, and is a local disease in every 
case; clap and chancre were present separately in different 
countries at different times. Mercury, which cures syphilis, is 
useless in clap. 

Clossius (1797) coincided with Bell's opinions, Evans and Le 
Bon (1789) strengthened them by experiments, but Hernandez 
(1811) first exercised a decisive influence and became a fore- 
runner of Ricord on account of the large number of his experi- 
ments (he inoculated seventeen convicts with gonorrhoeal pus, 
always unsuccessfully). 



Blenorrhcza of the Sexual Organs. g 

The dispute concerning- the identity of the virus of clap 
and syphilis led to the adoption of two extreme views. The 
investigations and experiments of Caron (1811) not alone in- 
duced him to deny the identity of the two poisons, but he 
denied the virulence of clap. Thus, Caron and his adherents, 
Jourdan (1826), Richond de Brus (1826), Devergie (1836), 
Desruelles (1826), taught that clap is devoid of any virus, that 
it is neither a virulent nor a contagious disease, but a simple 
genuine inflammation. In Germany, on the other hand, the 
careful study and observation of gonorrhoea and its course had 
led to its entire separation from syphilis, but its purely local 
character was also denied. It was regarded as a general 
disease and spoken of as a " clap diathesis." In the works of 
the adherents of this view— Authenrieth (1809), Ritter (1819), 
Eisenmann (1830)— we read not alone of clap but also of 
various sequelae or metastases, such as lung- clap, ear clap, 
g-onorrhoeal meningitis, clap ulcer, clap neuroses, gonorrhoeal 
amaurosis, congenital and acquired clap diathesis. 

Upon this confusion entered Ricord. Supported by large 
experience, critical and brilliant dialectic powers, but unfortu- 
nately, at the same time, deaf to all justifiable opposition to 
views which he had once regarded as correct, Ricord as the 
result of 667 inoculations, established the doctrine (1831 to 
1837) of the non-identity of the virus of clap and syphilis, and 
advocated it so clearly and pertinaciously that all opposition 
soon ceased and this view seems settled for all time. 

Although this question was settled, there developed with 
and on account of Ricord a new struggle, the struggle con- 
cerning the etiology of clap, and this we will consider in the 
folio wing- section. 

Etiology. 

Rieord's numerous inoculations and the acute reasoning- 
which accompanied them definitively separated gonorrhoea 
from syphilis, and although an identist voice was occasionally 
raised, the theory of the identists like that of Caron and Eisen- 
mann secured no adherents, although some distinguished 
specialists, like Yidal de Cassis and Simon, still favored it and 
now and then broke a lance for it. For the great majority 
g-onorrhoea remained permanently separate from syphillis. 



io BlenorrJioea of the Sexual Organs. 

But now arose a second important question : If clap is not 
produced by the syphilitic virus, is it the product of a virus at 
all, or is it a simple, non-virulent inflammation ? In addition 
to syphilitic clap — produced by the syphilitic virus, and which, 
in consequence of its development from the syphilitic virus 
was followed by syphilitic secondary symptoms — the ad- 
herents of the unitist theory, Brassavolus, Hunter and 
many others, had distinguished a simple genuine clap, which 
was supposed to occur as a simple catarrhal disease from 
various causes or even spontaneously. Now that the syphilitic 
clap disappeared, it was natural that the second variety, the 
simple clap, alone should be supposed to exist. 

And this, in fact, was taught by Bicord. He denied the 
virulence of clap, and regarded it as a simple catarrh which 
may be due to various irritants. Among these irritants he 
attached the chief importance to gonorrhceal pus, which repro- 
duced gonorrhoea merely by irritation, not as the result of a 
virus or contagious principle. But other secretions, menstrual, 
lochial and puerperal discharges and leucorrhcea, may also 
act as irritants and produce blenorrhcea. The same effect was 
said to result from acrid injections, introduction of instruments 
into the urethra, mechanical irritation, the ingestion of acrid 
food and drink. Even sexual excesses in perfectly healtlry in- 
dividuals, or mere long protracted sexual excitement and pro- 
tracted erections without coitus or sexual contact, were said to 
produce clap. Bicord based these views in part upon previous 
experience, especially Swediaur's experiments, in part upon 
confrontations. He laid special stress on the fact that in con- 
frontation in cases in which the male partner had acquired 
clap, the female was often found entirely healthy or often suf- 
ered merely from leucorrhcea, menstruation, etc., and the devel- 
opment of the clap must be attributed to one of the above- 
mentioned causes. Finally, he called attention to acclimatisa- 
tion, which renders one accustomed to it insensible to such 
irritation, but affects the new-comer with blenorrhcea. From 
all these experiences Ricord concluded that blenorrhcea is not 
a virulent disease, that it may develop without inoculation, 
that it may be acquired from the most innocent girl, the most 
virtuous wife. In his easy manner of presenting his views he 
even went so far as to devise a prescription for the means to 
be employed for surely acquiring blennorrhcea. I reproduce 



Blenorrhoea of the Sexual Organs. 1 1 

it, since it not alone contains the quintessence of his views on 
this subject, hut also furnishes an admirable characteristic of 
Ricord himself : " Do you wish to contract clap ? This is the 
way. Take a pale, lymphatic woman, blond rather than bru- 
nette, and as leucorrhceic as possible. Dine with her; begin 
with oysters and continue with asparagus, drink a good many 
dry white wines and champagne, coffee, liqueur. All this is 
well. Dance after your dinner and make your partner dance. 
Warm yourself up, and drink a good deal of beer during the 
evening. When night comes, conduct yourself bravely; two 
or three acts of intercourse are not too much, more are still 
better. On waking do not fail to take a long warm bath and 
to make an injection. If this programme is carried out and 
3^ou do not get the clap, it is because God protects you." 

These statements of Ricord first led to the experimental 
production of blenorrhoea by the introduction of genuine pus. 
Thus, in two individuals, Voillemier introduced into the urethra 
bougies which had been smeared with pus from an abscess of 
the thigh and neck. The bougies remained in the urethra an 
hour without producing clap. Other similar experiments 
proved negative, but the production of clap was always suc- 
cessful when the pus was taken from another clap or from 
conjunctival blenorrhoea (which was soon recognized as identi- 
cal), as shown by the experiments of Pauli, Guyomar and 
Thiry. Not alone was the difference between blenorrhagic 
and genuine pus determined in this way, but the advocates of 
the virulent nature of clap, the virulists, raised other objec- 
tions based upon observation. Thus, it was emphasized that 
in properly regulated marital life, the development of clap 
was not observed despite leucorrhoea, menstruation, or even 
the ichorous discharge of a uterine cancer. This is also true 
of localities which are shut off from communication with the 
outside world, and thus prevent little opportunity for the im- 
portation of clap, despite vigorous sexual intercourse or even 
excesses on the part of the inhabitants. Thus Rosolimos re- 
lates that the Greek farmers, who are very continent before 
marriage and are very faithful in marriage but commit the 
greatest excesses are unacquainted with gonorrhoea. Michaelis 
reports that the physicians practising in Lippe often did not 
observe a case of clap for years. Milton states that for several 
years he was the sole practitioner in a small town, and during 



12 Blenorrhcea of the Sexual Organs. 

this time treated several cases of clap, all of which proved to 
be imported, while he did not observe a single case acquired 
in the town, although there was no lack of opportunity for 
such acquisition. Further arguments are deduced from the 
course of blenorrhcea and comparisons with traumatic and 
chemically-produced urethral catarrhs. Thus, traumatic and 
chemical catarrhs develope immediately after the noxious 
action, have no tendency to propagation, but rather a tendency 
to spontaneous rapid recovery. On the other hand, virulent 
blenorrhcea has a period of incubation, a tendency to spread 
over the entire mucous membrane, and if not treated it does 
not heal spontaneously but passes into a chronic condition. 
The anti-virulists, who attributed the development of clap 
directly to the irritant action of the pus corpuscles and re- 
garded the intensity of the action as proportionate to the 
number of pus corpuscles in the secretion, were told that a 
minimum amount of mucous secretion, and one very poor in 
pus corpuscles, from a beginning or a chronic blenorrhcea, 
would suffice to produce a violent clap. 

In this way the struggle lasted for more than forty years, 
and sides were taken by very prominent writers. Among the 
anti-virulists were Acton, Hacker, M. Robert, Fournier, Langle- 
bert, Geigel, Mueller, Bumstead, Tarnowsky, Jullien; among 
the virulists were Baumes, Hoelder, Reder, Milton, Belhomme, 
Martin, Lebert, Sigmund, Zeissl, Diday. Finally, the latter 
began to gain ground, the anti-virulistic theory lost more and 
more supporters. One circumstance contributed materially 
to this change. A group of investigators were not satisfied 
with discussing the question of the existence of a virus in an 
academic manner, but attempted to discover the nature of the 
virus itself, and to determine its action. 

The theory that the virus of syphilis was a virus animatum 
was held at a remarkably early period of our specialty. Thus, 
in 1710, we read in a, it is true, very little known author, 
Deidier : u I believe that the venereal virus consists of nothing 
else but living maggots, which produce ova by copulation and 
which readily multiply as do all insects. These being assumed 
venereal diseases are explained much more readily than by 
any other hypothesis. . . . These maggots hatch and pro- 
duce others and in this way we can assume the propagation 
of the venereal virus. How can it be supposed, as is done, 



Blenorrhcea of the Sexual Organs. 13 

that pox could be carried from the Orient into Europe, and 
then pass, by commerce with a single prostitute, into the 
French army and thus to France, were it not for the venereal 
maggots which furnish a prodigious number of ova and which 
always find, in foul semen, the degree of putrefaction requisite 
to make them hatch ? " However naive the conception, the 
chain of thought is correct, and this man divined what could 
not be proven until two hundred years later. 

The followers of Deidier also adhered to the theory of the 
virus animatum, which the} 7 sought to discover. Donne (1837) 
called attention to the presence of an infusorium, which he 
called " trichomonas vaginalis," in the pus of blenorrhcea va- 
ginae, and he concluded from his investigations that: 1. Puru- 
lent vaginitis is very often blenorrhagic, and that the purulent 
discharge ordinarily contains the trichomonas ; 2. When it does 
not result from venereal infection, I am forced to conclude that 
it does not develop on account of these animalcules. Further 
investigations showed that the trichomonas was an accidental 
appearance, which is also present in healthy vaginal secretion. 
Jousseaume (1862) reports the discovery of an alga, which he 
called genitalia, in blennorrhagic pus. This discovery also 
proved illusory. Salisbury (1868) found threads of fungi and 
spores, which he called crypta gonorrhoica, in blenorrhagic 
pus; these were said to multiply in epithelium cells and to be 
found in the epithelium of the orifice of the urethra. Hallier 
(1868) published a similar discovery of a fungus with schizo- 
sporangia, which he called coniothecium; he produced cultures. 

Thiry (1819) formulated different views. He investigated 
the contagious Egyptian eye disease, determined its blenor- 
rhagic character by inoculations, made control inoculations 
of gonorrhceal pus into the eye, and came to the conclusion 
that in all these cases there was a contagious disease of the 
mucous membrane produced by the same virus. In the study 
of ocular blenorrhcea as distinguished from catarrh, the gran- 
ulations appeared to him to be the essential characteristic; 
they were present in all cases of blenorrhcea, absent in all 
cases of catarrh. Inasmuch as blenorrhcea reproduces blenor- 
rhcea, i.e., granulations reproduce granulations, he defined the 
former as a specific, contagious process, characterized by the 
formation of granulations, and he applied the term "virus 
granuleux" to its contagious principle. There is no blenor- 



14 Blenorrhcea of the Sexual Organs. 

rhoea without granulations, and hence Thiry demonstrated 
their presence in the blenorrhagic diseases of the vagina and 
uterus. Desormeaux (1865) showed their presence in the ure- 
thra by examination with the endoscope. 

A decided change in this question did not occur until the 
new etiological impetus of pathological anatomy, which was 
prepared by Hallier, Pasteur and Klebs, and inaugurated by 
Koch, began to make its way. In 1879 A. Neisser reported a 
micrococcus peculiar to gonorrhoea, which he found constantly 
in the pus of clap and gonorrhoeal conjunctivitis by means of 
Koch's staining* methods. In 1880 these statements were con- 
firmed by Bokal and Finkelstein, who not alone corroborated 
the constancy of occurrence of the gonococci, but also stated 
that they had cultivated them and had produced acute ureth- 
ritis in two cases by inoculation of the cultures into the ureth- 
ra. Further corroborative investigations followed rapidly. 
Weiss (1880) and Aufrecht (1880) noticed the presence of the 
gonococci in a large number of urethral blenorrhoeas. Haab 
(1881) found that the cocci of blenorrhoea neonatorum were 
absolutely identical with gonococci. Hirschberg and Krause 
(1881) found the cocci in all cases of blenorrhoea neonatorum, 
but claimed to have demonstrated similar forms in simple 
catarrhs, and in the vaginal secretion of healthy women. 
Sattler, Hirschberg and Lebert (1881) agreed with the state- 
ments of Neisser. In 1882 Neisser himself published a detailed 
communication in which he describes the shape of the gono- 
cocci and their mode of increase, and also partly successful 
attempts at culture. Krause (1882) also reported similar re- 
sults concerning blenorrhcea conjunctivae. As the result of a 
large series of investigations Leistikow (1882) came to the 
conclusion that the microscopical demonstration of gonococci 
in a secretion proves its blenorrhagic character. Culture ex- 
periments which he made with Loeffler, proved unsuccessful. 
Ecklund (1882) stated that he found the gonococcus in all pos- 
sible secretions, and therefore denies its specific character. 
On the other hand he found constantly, in blenorrhoea, a fun- 
gus, ediophyton dictyodes, which is also present in the dis- 
charges of summer diarrhoea and dysentery and in the urine 
in scarlatina, and this he claims is the virus of blenorrhoea ( ! !). 
In 1883 appeared a noteworthy publication by Bockhart. 
He first laid stress, on the constant finding of gonococci in 



Blenorrhoea of the Sexual Organs. 1 5 

258 cases of blenorrhoea, then reports the successful culture 
and inoculation of the pure culture in the urethra of a paraly- 
tic, who suffered in consequence from a subacute urethritis. 
At the autopsy (the patient died of pneumonia ten days 
after the inoculation) were found renal abscesses, pyelitis 
and cystitis, which were infiltrated with masses of cocci. 
Microscopical examination of the urethral mucous membrane 
showed inflammatory infiltration, with accumulation of cocci 
in the lymphatic vessels. Bockhart's results, both as regards 
the pure culture and inoculation and also the microscopical 
appearances, were combatted, the former by Loeffler, the 
latter by Arning. Loeffler denies the genuineness of the gono- 
coccus pure culture, and Arning- maintains that the cocci heaps 
described by Bockhart in the lymphatics were really mast 
cells. In the same year appeared corroborative articles by 
Eschbaum, Newberry,Campona, Marchiafava and Keyser. The 
latter examined 64 cases (30 whites, 34 negroes) of urethral 
blenorrhoea, and found the gonococcus constantly. They were 
absent only in two treated cases and in one recent case with 
scanty secretion. Equally positive results were afforded in three 
cases of ocular blenorrhoea in adults, and one case of blenor- 
rhoea neonatorum. Numerous control examinations of various 
kinds of pus always gave negative results. Sternberg (1883), 
however, denied the specific character of the gonococcus, which 
he regards as identical with the micrococcus ureas. In 1884 ap- 
peared the article by Zweifel, who showed that only gonococci- 
containing, but never gonococci-free, lochia! secretion is able 
to produce blenorrhoea neonatorum. Bumm isolated a series of 
other diplococci found in the vaginal secretions, and studied 
their morphological characters and virulence by means of cul- 
tures and inoculations. He also claims to have found gonococci 
constantly in those lochial secretions which had given rise to 
blenorrhoea neonatorum. Welander reports similar results. In 
25 confrontations, which he undertook, he found gonococci iu 
both partners; inoculation of vaginal secretion, which was free 
from gonococci, into the male urethra always gave negative re- 
sults, while he obtained typical positive results in three cases 
when small amounts of gonococci-containing pus were placed in 
the male urethra. Further positive results were obtained by 
Chameron, Wyssokowitch and Belleli, the latter making his 
investigations in an examination bureau for prostitutes. 



i6 Blenorrhcea of the Sexual Organs. 

Aubert found the gonococcus in more than 200 cases of blenor- 
rhoea and he regards it as the most frequent cause of clap. 
But in a few cases of urethritis, which were followed by epi- 
didymitis and cystitis, he found no gonococci, but always the 
same variety of bacteria, so that, in addition to the most viru- 
lent and frequent blenorrhcea-producer, the gonococcus, he dis- 
tinguishes other, less frequent, virulent micro-organisms. In 
1884 Sternberg published a paper for the opposition, in which 
he denied the specific character of the gonococcus on account 
of the negative results of very questionable pure cultures. 
Gama Pinto found gonococci in all kinds of pus, so that he 
does not regard them as specific, but as secondary, since he 
often found them only at a late period, the third or fourth 
day of suppuration. Kroner distinguishes two forms of blen- 
orrhcea neonatorum, a more frequent one with gonococci, a less 
frequent one without this bacterium. Saenger and Fraenkel 
combat the diagnostic significance of the gonococcus, whose 
absence does not exclude blenorrhagic disease. Oppenheimer 
studied the influence of various anti-gonorrhoics upon g-ono- 
cocci pure cultures. In 1885 Lundstroem and Kreis published 
similar experiments. The former examined 50 cases of acute 
and chronic urethritis, and always found gonococci. The viru- 
lent character of the gonococcus received further support 
from Martineau, Ferrari, Pezzer, Sinety and Henneguy. In 
1886 Bockhart published investigations on 15 cases of "pseudo- 
gonorrhceal " urethritis, two of which were followed by epididy- 
mitis and were not produced by gonococci, but by other micro- 
organisms, as Bockhart proved by cultures and inoculation. 
Podres, Petersen and Creveili furnished corroborating evidence 
based on large experience and numerous investigations, while 
"Giovannini and M. v. Zeissl denied the specific character of 
the gonococcus. Schwarz (1880) pleaded for the gonococcus. 
Finally Bumm's treatise (188?) adduced abundant material 
and incontrovertible proof of the virulent character of the 
micro-organism. The possibility of making* cultures of the 
gonococcus has been increased to such an extent, especially 
since the introduction of Wertheim's method (1891), and so 
many positive inoculations have been made, that doubt of the 
pathogenic character of the gonococci is hardly possible at the 
present time. In fact, its etiological significance is now rec- 



Blenorrlioea of the Sexual Organs.. \J 

ognized universally, except by a small group of French 
writers (Eraud). 

And now, after this historical digression, we will direct our 
attention to the gonococcus itself, and examine its nature and 
the proofs of its virulence. Neisser's gonococcus is a diplo- 
coccus. Under feeble powers and unstained the gonococci 
appear as round or elongated round fungi, 1.25 m. long, 0.7 m. 
broad, but which, under high powers and after staining, are 
seen to be divided into two uniform halves by a bright line, a 
split. Each of these halves has an outer convex and an inner 
straight contour, both lie close to one another along the straight 
contour, so that only a thin slit remains between them. Each 
half of the diplococcus thus resembles a coffee bean. The 
gonococcus presents these characteristics in common with all 
diplococci. A further characteristic is furnished by the group- 
ing. It is never grouped in chains, but is always found in 
small groups and clumps, and the number of single individuals 
in each group is not alone paired but is usually divisible by 
four. This grouping results from the peculiar mode of fission, 
as described by ISTeisser. Each diplococcus pair (Plate III., 
Fig. 4) divides in a line at right angles to the median fissure, 
so that from one diplococcus develop two double pairs, which 
are arranged like sarcina, but are usually a little more closely 
aggregated. Inasmuch as each single diplococcus pair again 
divides into a sarcina-like, double pair, and these shift from 
one another, groups develop in w^hich many cocci pairs are still 
seen alongside one another in twos and twos. But these 
methods of division are also found in other diplococci. Like 
other bacteria, the gonococcus also possesses a great power of 
attraction for basic aniline colors, is readily stained by methyl 
violet, dahlia, gentian violet, fuchsin and methyl blue, but is 
decolorized with equal facing in alcohol and acids, according 
to Gramm's staining. This ready decolorization is a negative 
but extremely valuable diagnostic sign between the gono- 
coccus and other forms of cocci, which usually retain a once 
imbibed staining much more vigorously and are not decolor- 
ized either by alcohol or acid, and particularly by Gramm's 
method. Roux (1886) recommended decolorizing according to 
Gramm, especially as a differential diagnostic sign. Allen 
(1887) was the first to advocate the differential diagnostic 
value of decolorization according to Gramm. Bumm (1887) 
2 



1 8 BlenorrJioea of the Sexual Organs. 

denied this, in view of the fact that other diplococci of gonor- 
rhoeal pus are decolorized by Gramm/s method, but I (first 
edition of this work), and later Steinschneider and Galewsky 
(1889), have again emphasized its importance on the basis of 
careful investigations. The latter writers have shown that four 
kinds of diplococci are found in the normal urethra as well as in 
the secretion of blenorrhcea. The two more frequent ones re- 
tain a milky white and an orange yellow color after Gramm's 
staining, while the two rarer forms are grayish-white and 
citron yellow, occur only in the proportion of 4.6 to 4.8 per 
cent, and like the gonococcus are decolorized. Hence Gramm's 
decolorization of the gonococcus furnishes positive results in 
95.35 per cent of the cases. Steinschneider and Galewsky color 
the cover glass for twenty-five to thirty minutes in aniline 
water gentian violet, then rinse the glass, then place the prepa- 
ration for five minutes in the iodide of potassium-iodine solution. 
After repeated rinsing in water it is placed in absolute alco- 
hol until the preparation is decolorized, and the alcohol which 
drips from the cover glass no longer has a violet color. After- 
staining in Bismarck brown. The gonococci then have a 
brown color; all other cocci are black from the combination 
of the gentian violet and Bismarck brown staining. Over- 
staining with Bismarck brown is to be avoided because this 
obliterates the difference in color. After-staining with fuch- 
sin is more practicable. According to my experience the fol- 
lowing is the best method of staining. The pus, which is 
spread upon the cover glass in the usual manner, dried and 
fixed by drawing it through the flame, is placed, with the 
charged side downwards, upon the solution of methyl blue. 
This is prepared by dropping a concentrated alcoholic solution 
of methyl blue into water or a solution of caustic soda (1 : 10000) 
in a watch glass until the fluid has a dark blue color. At the 
end of two minutes the cover glass is removed, washed with 
water, dried, and placed upon the object glass with Canada bal- 
sam. In this way the cocci appear dark blue and contrast very 
distinctly with the grayish-blue nuclei and the very pale blue 
protoplasm. Bumm recommends a practical rapid staining. 
The pus is spread in a thin layer upon the object glass with 
the blade of a knife, dried over the flame, drawn through the 
latter, exposed for half a minute to a concentrated watery 
solution of fuchsin, washed off, dried over the flame, and ex- 



Blenorrhcea of the Sexual Organs. 19 

amined without a cover glass in the oil of the homogeneous 
immersion lens. 

Schuetz (1889) recommends the following method for stain- 
ing gonococci. The cover glass with the clap pus is placed 
for five to ten minutes in a 5-per-cent solution of carbol-methyl 
blue, then washed in distilled water and in dilute acetic acid 
(acid acetic dil. gtt. i. : aqua 50), and then stained with a 
watery solution of safranin. The gonococci have a blue color, 
the epithelium is pale blue, the pus cells, their nuclei, and the 
nuclei of the epithelium cells, are salmon color. This method 
is not reliable, and is unavailable for differential dignosis. 
Very beautiful results are furnished by a double staining with 
eosin-methyl blue, as done by Klein in Prof. Weichselbaum's 
Institute. The cover glasses, charged with clap pus, are first 
placed for forty minutes in a mixture of alcohol and ether, aa, 
and then for ten to fifteen minufces in an eosin-methyl blue 
solution (0.5 eosin in 100.0 concentrated watery solution of 
methyl blue); they are then washed in water, dried, and 
placed with Canada balsam on the object glass. The gono- 
cocci cell nuclei appear blue, the protoplasm salmon color. 
The intracellular position of the gonococci in the pus cells is 
especially distinct. 

If we examine preparations of gonorrhceal pus treated in 
this way (Plate III., Figs. 5, 6, 7), we will usually be able to 
find numerous gonococci in groups, provided that the clap is 
recent and has not been treated. These groups are situated 
partly between the cells, partly — and this is characteristic 
of the gonococcus— in the pus cells. Thus, we find cells in 
which a single group or a few groups of gonococci are situated 
in the protoplasm, usually near the nucleus. In other cells the 
number of gonococci is larger, they extend on one side or the 
other to the edge of the cell, but never beyond it, thus proving 
their presence within, not upon the cell body. Finally, other 
cells are so full of gonococci that they conceal the nucleus. 
When this takes place the cells burst and the groups of cocci 
escape from the cells. We then find not infrequently that 
groups of cocci are arranged around one, two or three cell 
nuclei, but without the sharp contour of the cell body; they 
are generally aggregated more closely towards the middle, 
more loosely towards the periphery. 

In order to prove the specific character of these cocci, it is 



20 Blenorrhcea of the Sexual Organs. 

necessary not alone to demonstrate their constant occurrence 
in blenorrhagic secretion, but also to make pure cultures and 
inoculations with the result of producing- a "blenorrhcea. Apart 
from other observers who made statements concerning' suc- 
cessful pure cultures, but whose nature as gonococci pure cul- 
tures was not proven by inoculation, or in which negative re- 
sults were obtained, Bumm reports incontestable pure cultures. 
After several unsuccessful attempts this writer employed for 
cultures human blood serum, which he obtained from placentae 
and sterilized in the well-known way. The pus of urethritis 
taken from the deep parts of the urethra, is spread in drops 
upon the blood serum, and the test tubes are then exposed to 
a temperature of 37° C. in the incubator. On the following day 
the gonococci have increased considerably in the drops which 
have sunk into the blood serum. This secretion which is infil- 
trated with numerous gonococci, is now conveyed in drops 
upon delicately gelatinized blood serum, upon which the migra- 
tion of the gonococci from the secretion to the blood serum 
takes place. The growth of the culture ceases at the end of 
two or three days, and reinoculations must therefore be per- 
formed frequently. 

The coccus colony now appears as an almost colorless, thin, 
lac-like shining coating- of the surface of the blood serum, 
which presents a somewhat characteristic appearance from 
the fact that it has a tendency to spread in numerous jagged, 
steep projections. Transference of the culture to meat infu- 
sion, pepton, gelatin, agar, always was attended with nega- 
tive results. The gonococci did not grow in these media. 

In two cases Bumm found that the conveyance of a second 
and a twentieth generation of a gonococcos pure culture to 
the female urethra produced a typical acute urethritis, the pus 
of which contained numerous g-onococci. 

Soon afterward (1891), Aufuso made pure cultures of gono- 
cocci in the fluid of hydrarthros and obtained positive results 
on inoculating the male urethra. 

Wertheim (1892) had done material service in cultivating 
the gonococcus and in demonstrating its pathogenic charac- 
ter. He returned to the plate method first recommended by 
Bockhart (1886). Human blood serum, obtained from the 
placenta, is treated with gonorrhoea! pus; two dilutions are 
then prepared; and about 3 cm. of the preparation is mixed 



Blenorrhcea of the Sexual Organs. 21 

with an equal amount of liquefied nutrient agar (2 per cent 
agar, 1 per cent peptone, 0.5 sodium chloride) and poured into 
plates. 

Colonies, which are visible as delicate, whitish-gray dots, 
develop very rapidly, usually at the end of twenty-four hours. 
With low magnifying powers the deep colonies appear yel- 
lowish-gray, coarsely granular, while the superficial colonies 
show a delicate superficial layer around a compact, punctate 
centre. Inoculation of these colonies upon obliquely coagu- 
lated blood serum produces the delicate gray colonies de- 
scribed by Bumm, either with a jagged contour or consist- 
ing of small dots. Inoculation of this culture into the male 
urethra, in five cases, always showed a typical positive effect 
(two to three days' incubation, four to to five weeks' acute 
urethritis containing gonococci). The microscopical examina- 
tion, shape, ready decolorization with Gramm's method, and 
cultures also undoubtedly proved that they were gonococci. 
The pure cultures thrive not alone upon blood-serum, but also 
upon simple nutrient agar with or without the addition of 
glycerin. They also thrive very well upon blood-serum agar 
(one part human blood serum, two parts bouillon-peptone 
agar), and here produce delicate, whitish patches, with ser- 
rated edges. They also thrive in a mixture of one part hu- 
man blood serum with two parts peptone bouillon. Here they 
grow upon the bottom of the eprouvette as loose, transparent, 
scale-like crumbs, while the surface is covered by a delicate 
grayish- white layer. The serum of cow's blood mixed with 
peptone agar also furnishes an excellent nutrient for the 
gonoccoccus. 

A material simplification of the method of culture was de- 
vised by Ghon and Schlagenhaufer in Prof. Weichselbaum's 
Institute. Their experiments are not yet completed, but, 
with their permission, I publish the following notes. Wert- 
heim had produced direct pure gonococcus cultures by applica- 
tion upon obliquety coagulated agar, to which human blood 
serum had been added. Ghon and Schlagenhaufer avoid the 
complicated plate method entirely, by placing the clap pus (ob- 
tained from the urethra after cleansing and disinfection of the 
orifice) directly upon Pfeiffer's agar (i.e., glycerin agar, whose 
surface has been thinly smeared with human blood taken 
from the lobe of the ear) or upon Petri's cups filled in a simi- 



22 Blenorrhcea of the Sexual Organs. 

lar manner. The same tip is employed for the application of 
several cultures, and dilutions are thus made so that isola- 
tion of the gonococcus cultures is possible in case of soiling-. 
Very beautiful pure cultures are also furnished in Peter's 
cups, spread with cow's blood-serum-peptone agar, and inoc- 
ulated in the same way. A typical positive result was ob- 
tained in eight inoculations of the male urethra which Ghon 
and I made, for therapeutic purposes, upon different indi- 
viduals, some of whom were already suffering from chronic 
blenorrhoea. The appearance of the cultnres,' their behavior 
under Gramm's method, corresponded entirely to the descrip- 
tions of Bumm and Wertheim. 

If we make a resume of the investigations just referred to, 
the following facts may be regarded as well established : 

1. The gonococcus is found in all cases of suppuration of 
the mucous membranes, especially of the genitalia and con- 
junctiva, which are described clinically as gonorrhceal. 

2. It is absent in all non-gonorrhoeal processes. 

3. Pus free from gonococci does not produce gonorrhoea 
(Zweifel, Welander). 

4. Pus containing gonococci produces gonorrhoea (We- 
lander). 

5. The micro-organisms which are cultivated from gonor- 
rhceal pus, but which are not identical with the gonococcus, 
do not produce gonorrhoea (Sternberg, Lundsohem, Cham- 
eron). 

6. The gonococci cultivated from gonorrhceal pus produce 
gonorrhoea, with distinct increase of the inoculated micro- 
organisms (Bumm, Aufuso, Wertheim, Ghon, Schlagenhaufer, 
and I). 

Thus the etiology of gonorrhoea is well established, its 
virulence and virus are proven. We shall discuss the occur- 
rence and diagnostic significance of the gonococcus in the 
special part. 



CHAPTER I. 

BLENORRHCEA IN THE MALE AND ITS COMPLICA- 
TIONS. 

URETHRAL BLENORRHCEA. 

Anatomical and Physiological Remarks. 

Blenorrhcea of the male urethra is probably the most 
frequent disease with which the practical physician has to 
deal. With it he usually begins his early practice, and until 
the end it causes him many anxious hours. Frequent as is the 
disease, it is equally ungrateful as regards a positive and 
radical cure. The practitioner is often told by his patients, 
either openly or by intimation, that he cannot even cure a clap, 
and the specialist often hears the same thing from his prac- 
tising colleagues. A part of the blame attaches to the patient 
and to our social conditions, which render it impossible for the 
most honest and conscientious patient to follow all the medical 
directions without compromising* himself, unless he were to 
undertake " a trip South for the restoration of his impaired 
health." But the physician is in great part to blame. We 
venture to assert boldly that there is no department of general 
medicine in which such unscientific and routine treatment is 
adopted as in the case of blenorrhcea. A clap syringe of tin, 
hard rubber or glass, a collection of thirty to forty recipes for 
injections, are the entire armament of the large majority of 
physicians. Certainty of diagnosis by examination of the pus 
and urine, the methods of physical examination of the urethra, 
are usually terra incognita in the pathology and treatment 
of gonorrhoea. No wonder, then, that this so frequent disease 
is a true crux medicorum and forms the " parti e honteuse " 
of general medicine. 

It is only within the last ten years that some light has been 



24 BlenorrJiooa of the Sexual Organs. 

shed upon this darkness. Our long-known anatomical and 
physiological data began to be made available in the pathol- 
ogy of urethritis; diagnosis and localization were thus placed 
upon a positive basis, and the indications for treatment were 
shown more clearly. 

The more recent diagnosis, pathology, and treatment of 
urethritis are based on an anatomical, physiological, and 
bacteriological foundation. 

It is not my purpose to write a detailed anatomical and 
physiological treatise. I shall content myself with presenting 
those points in the anatomy and physiology of the urethra 
and bladder w r hich constitute the immediate basis of our 
diagnostic and therapeutic action. 

The question of the width, diameter, and dilatability of the 
urethra is an important one. It is a generally recognized 
fact that the calibre of the urethra is not uniform but subject 
to variations. These are visible when the urethra is merely 
slit up. If a perfectly normal urethra is slit lengthwise (Fig. 
1), we find, on beginning at the orifice, immediately behind 
the latter, a dilatation, the fossa navicularis, a, behind this 
the urethra is somewhat narrowed and passes through the 
greater part of the pars cavernosa with tolerably uniform 
calibre, b. 

At its posterior extremity begins a spindle-shaped dilata- 
tion, the bulb, c. Posteriorly this terminates quite abruptly, 
where the urethra enters the isthmus, and, during its passage 
through the diaphragma urogenitale, the urethra, which here 
bears the name pars membranacea, d, has a tolerably uniform 
size. Immediately after the exit from the diaphragm, i.e., at 
the entrance into the prostate, the calibre of the canal again 
increases and it forms a spindle-shaped dilatation, e, which 
attains its greatest width at the caput gallinaginis, and, 
when the bladder is empty, again becomes somewhat nar- 
rower towards the entrance to the bladder. 

A mould of the urethra therefore consists of several parts; 

1, the fossa navicularis, a spindle which is broken off anteriorly; 

2, pars cavernosa, which is uniformly tubular; 3, the bulb, a 
spindle which is broken off posteriorly; 4, pars membranacea, 
a short tube ; 5, pars prostatica, a symmetrical spindle. 

Of all these parts the orifice of the urethra is the narrow- 
est; its width is given at 8 millimeters (24 of Charriere's 



Blenorrhcea of the Sexual Organs. 



25 



scale), but it is often narrower. Under normal conditions, a 
sound which has passed the orifice will always pass through 
the remainder of the urethra 
without obstruction. But if the 
orifice is wider, as sometimes 
happens, or if it has been di- 
lated, as is sometimes necessary 
in operative procedures, we can 
convince ourselves that a much 
larger size may pass through the 
remainder of the urethra with- 
out hindrance; the dilatability 
of the remainder of the urethra 
is much greater than that of the 
orifice. This dilatability is not 
uniform, but differs in different 
parts. The pars membranacea 
comes next to the orifice, then 
the pars pendula, then the pars 
prostatica; finally the bulb, the 
widest and most dilatable. We 
usually speak of the calibre of 
the urethra as distinguished 
from its dilatability, but this is 
not correct. The urethra, whose 
walls, as can be seen with the 
endoscope, touch at a point or 
slit, possesses no calibre or only 
a minimum one. The passage 
of the smallest instrument 
through the urethra is only pos- 
sible by the stretching of the 
walls, by their yielding to the 
pressure of the instrument. This 
is also true of the stream of 
urine which stretches the mucous 
membrane owing to the pres- 
sure of the contracting bladder. 
Hence the stream, when the 
bladder is paretic, is not alone 
feeble but also narrow, so that fio. 1. 




26 



Blenorrhcea of the Sexual Organs. 



it may simulate a stricture. During- normal micturition the 
walls of the urethra are never stretched to the maximum, as 
can be easily demonstrated. If the external orifice is sud- 
denly closed during* micturition, further 
distention of the urethra will follow. 

While the meatus as far as the fossa 
navicularis is dilated only to a slight 
extent, the remainder of the mucous 
membrane is much more dilatable. As 
the result of changes in the walls — 
chronic hyperplasia of the connective 
tissue and cicatrices — which diminish the 
elasticity, this dilatability may be more 
or less diminished in circumscribed spots. 
In order to measure the width of the 
various parts of the urethra in cases of 
narrow meatus and without dividing the 
latter, Otis and Weir devised the so- 
called urethro meters (Figs. 2 and 3). 
These consist of straight catheters which 
open at the visceral end either in a hemi- 
sphere or spindle, and are covered with 
a rubber cap in order to prevent pinch- 
ing of the mucous membrane. A screw 
at the outer end effects the dilatation of \ 
the hemispheres or spindle and indicates 
the diameter of the latter in numbers 
of the Charriere scale by means of a 
hand upon a dial plate. If such an 
urethrometer is introduced closed into 
the urethra — and this is done without 
difficulty by one who is expert in the 
introduction of straight instruments 
into the canal — we are able, in the pars 
prostatica (as I have convinced myself 
in numerous examinations), to dilate the hemisphere or spindle 
to 40 or 45 of the Charriere scale, i.e., to a diameter of 12 to 
15 millimetres, without feeling any resistance or causing an 
expression of pain on the part of the patient. But resistance 
is experienced at once if an attempt is made to withdraw the 
dilated instrument and the pars membranacea is approached. 




Fig. 2. 



Fig. 3. 



8 mm. 


21 to 24 Char 


11 " 


30 u 33 


9 " 


27 


10 " 


30 


12 " 


36 


9 " 


27 


10 " 


30 


15 " 


45 


11 " 


33 



Blenorrhcea of the Sexual Organs. 2J 

Here the instrument must be screwed down to 27 or even 26 
in order to pass without obstruction. At the bulb it again 
becomes possible to dilate to 40 to 50 Charriere. The pars 
cavernosa usually admits the passage of 30 to 35, and the 
orifice is only permeable to 24. 

Kollet (1862) gives the following measurements for the 
different parts of the slit male urethra in the dead body : 

Orifice . . . 7 to 

Fossa navicularis . . 10 " 
Immediately behind the latter . 
Middle of pars cavernosa . 

Bulb 

Pars membranacea (middle), 
Pars prostatica (beginning), 

(middle), . 

(end), 

The importance of the calibre and dilatability of the vari- 
ous portions of the urethra will receive special attention in 
the section on diagnosis. 

A second question which interests us deeply concerns the 
muscular apparatus of the urethra and bladder. 

The urethra is usually divided into a pars pendula, bulbosa, 
membranacea and prostatica, but this division has only a 
secondary importance for us. The division of the urethra into 
an anterior urethra — up to the isthmus — and a posterior 
urethra — behind the isthmus — possesses great diagnostic and 
therapeutic significance. This division is not arbitrary, but 
has an anatomical, developmental and functional basis. Ana- 
tomically, because the structure and surroundings of both parts 
are essentially different. The anterior part, which includes 
the pendulous and bulbous portions, is surrounded by erectile 
tissue, whence it is also called pars cavernosa. In the posterior 
part, the erectile tissue becomes insignificant and the most 
prominent feature is the abundant surrounding muscular layer, 
whence the term pars muscularis. Both portions of the urethra 
are also essentially different from a developmental point of 
view. According to Picard (1885) the urogenital sinus forms 
the entire urethra in the female, and only the posterior urethra 
in the male. The formation of the anterior urethra is en- 



28 Blenorrhoea of the Sexual Organs, 

tirely independent. This develops from a nodule (phallus) 
which springs from the anterior wall of the cloaca, grows, and 
receives a groove on its lower surface, which closes in to form 
the anterior urethra. Finally, there is a functional difference 
between both parts of the urethra, inasmuch as the posterior- 
part with its muscular layer forms an integral part of the 
uropcetic system, while the anterior urethra plays only a pas- 
sive part in micturition, but, on the other hand, forms with. its 
corpora cavernosa an essential portion of the sexual apparatus, 
and serves as the organ of copulation. 

To what extent this division is justified in the pathology of 
blenorrhoea will be discussed in the appropriate chapters. 

The quite simple anatomical structure of the pars cavernosa 
does not require our attention, but we must consider in detail 
the pars posterior seu musculosa. 

We will first study its posterior portion, the pars prostat- 
ica. This owes its name to the surrounding prostate, an 
organ which is usually described as a gland, but possesses a 
much more complex structure. The investigations of the older 
anatomists, but particularly those of Henle (1863) and Langer 
(1885), showed that the inner surface of the prostate (which is 
directed towards the bladder) is formed by a sphincter com- 
posed of organic, smooth, muscular fibres, which is prismatic 
in shape, triangular on section and of very firm structure. It 
surrounds the urethra like a ring (Plate I, Fig. 1, A and B). 

The smooth muscular tissue is mixed with numerous elastic 
fibres, and the network is made still denser from the fact that 
smooth muscular fibres as well as elastic fibres, which come 
from the bladder, cross these circular bundles. This smooth 
annular muscle is called the internal sphincter of the bladder, 
but preferably the internal prostatic sphincter. To the outside 
of this sphincter, i.e., at the middle of the pars prostatica, the 
glandular portion of the prostate increases. It forms an 
acinous gland which, in well-developed cases, has the shape of 
a seal ring whose broad plate occupies the lower surface of the 
urethra, which is directed towards the rectum, while the nar- 
row ring-shaped portion surrounds the urethra. The prostatic 
gland is rarely so f ully developed ; the upper portion, inclosing- 
the urethra, is not quite complete, and the prostate then 
surrounds the urethra below and on the sides in the shape of 
a half -ring, which grows smaller above, but leaves the upper 



Finger 



Plate I. 



Fig. 1. 
A 



\> , 






,\ 





^**&0Z 







D (I 







Ble?torrhcea of the Sexual Organs. 29 

portion of the urethra free. This gland forms the boundary 
between the above-mentioned sphincter and a sphincter which, 
situated in front of the gland (the most anterior portion of the 
pars prostatica), occupies the apex of the prostate. Unlike 
the internal sphincter, this muscle — the external vesical or 
prostatic sphincter — is formed only in part of smooth muscle, 
but in great part of voluntary muscular fibres. The smooth 
fibres form a ring or network immediately in front of the 
gland. The voluntary fibres at first appear only at the upper 
end of the urethra (Plate I, Fig. 1, C and D), and are in direct 
apposition to the gland or, as this is often absent, to the fibres 
of the internal sphincter. These fibres cross the urethra and 
form a muscular layer which passes transversely over the 
urethra, from one lobe to the other. Contraction of these 
fibres would approximate one lobe of the prostate to the other, 
but as this gland is very firm and but slightly flexible, the 
lobes form fixed points, and the arched muscle between them, 
in shortening, loses its curve, and becomes straight, and thus 
compresses the urethra from above downwards. These mus- 
cular fibres form what Krause and Kohlrausch call the 
transverse urethral muscle. To these fibres are soon added 
others, which surround the urethra laterally and below (Plate 
I, Fig. 1, E), and when the urethra leaves the apex of the 
prostate, it is entirely surrounded by a complete sphincter of 
voluntary muscle (Plate I, Fig. 1, F). This muscle, which is 
composed of smooth and voluntary muscular fibres, we call 
the external vesical or prostatic sphincter. 

As soon as the urethra leaves the apex of the prostate it 
enters the urogenital diaphragm, which it leaves again at the 
isthmus, and within which it is known as the pars membran- 
acea. Despite its title of pars nuda it is surrounded by a 
broad layer of smooth and voluntary muscular fibres. This 
muscular layer has received the most diverse descriptions and 
consideration at various times. Observed by Winslow and 
Santorini, Wilson (1821) was the first to study it in detail. 
Guthrie (1836), Mercier (1845), Demarquay (1849) give different 
descriptions, nor are concordant opinions found among the 
German anatomists Meckel, Mueller, Arnold, Krause and 
Kohlrausch, Hyrtl, Henle, Luschka, down to Lesshaft (1873). 
But the great abundance of muscular tissue in the pars mem- 
branacea is evident from all the investigations, however 



30 Blenorrhcea of the Sexual Organs. 

much they may vary in details. All accounts agree that it 
is covered by a broad layer of smooth muscular fibres, which 
consist of an inner layer of longitudinal, an outer layer of 
circular fibres. Henle (1863) puts the thickness of the longi- 
tudinal layer at 0.3 mm., of the circular layer at 0.75 mm.; 
Robin and Cadiat (1874) give 0.5 to 0.8 mm. for the former, 
1.0 mm. for the latter. Outside of this is a broad layer of 
voluntary muscular fibres, whose individual strands surround 
the urethra like a ring internally, while the outer fibres pass 
above and below the transverse urethral muscle from one side 
to the other; finally, other fibres, which come from the deep 
transverse muscle of the perineum, surround the urethra like 
a loop. This muscular apparatus is termed the musculus 
compressor partis membranacea, or, in brief, the compressor 
urethrae. 

It is evident from the statements just made that the pros- 
tatic and membranous parts are usually in a condition of 
tonic contraction. This contraction is produced by the tonus 
of the smooth muscular fibres surrounding these parts, and 
can also be made visible very clearly through the endoscope. 
If this instrument is inserted into the most posterior portion 
of the urethra, up to the bladder, and is then gradually with- 
drawn while the appearance of the mucous membrane is being 
watched, we will see that the mucous membrane (which forms 
a funnel, starting- from the visceral edge of the endoscope and 
with its tip directed towards the bladder) is continually clos- 
ing- up pari passu with the slow withdrawal of the endoscope, 
and leaves only a punctate lumen. This tonic contraction of 
the mucous membrane subsides during micturition by reflex 
action, but it can be markedly increased by innervation of the 
transversely striated muscular fibres which are accessible to 
the will. 

Both posterior portions of the urethra are accordingly 
closed ag-ainst the bladder, and their muscular tonus alone, 
which may be further increased by voluntary impulse, will 
suffice to prevent the escape of urine from the bladder. 

Let us now consider the muscular structure of the bladder. 
Its three layers of smooth muscular fibres, — an inner layer of 
circular fibres, a middle layer of meshed fibres, and an outer 
layer of radially distributed fibres — will always produce dim- 
inution in the size of the bladder during contraction, and thus 



Blenorrhoea of the Sexual Organs 31 

act as a detrusor. Has the bladder a special sphincter, and 
can it retain the urine independently without the intervention 
of the urethral muscular tissue ? Anatomists have been oc- 
cupied with this question for a long- time. The attempt was 
made to construct such a sphincter of the bladder or to explain 
the closure of the organ in another way. Thus, Guthrie (1836) 
states that he could find neither circular nor spinal fibres at 
the neck of the bladder, and he is therefore of the opinion that 
the vesical neck possesses little muscular contractility but 
marked elasticity. Civiale (1850) declares that the question 
of the existence of a sphincter at the neck of the bladder is the 
most obscure point in the anatomy of the organ. Anatomists 
express divergent views. Some assume the existence of a 
sphincter, but only by induction ; others regard the ring at the 
neck as a mechanical obstruction. Civiale himself found 
circular fibres very inconstantly and sparely in this ring, and 
regards the main feature as a labyrinth of longitudinal and 
spiral fibres passing- to the prostate. Barkow (1858) locates 
the occlusion of the bladder in the annulus elasticus cervicis, 
but, like the writer just mentioned, believes that the main 
occlusion of the bladder is formed by the muscular tissue of 
the pars prostatica and membranacea. Henle (1863) acknowl- 
edges the existence of a thin bundle of smooth muscular fibres 
at the neck of the bladder, but does not regard it as a sphincter ; 
its contraction can have no other effect than to narrow the 
lower part of the bladder and to aid in the complete evacua- 
tion of the urine. Henle also places the real sphincter of the 
bladder in the prostate. Wittich (1859) also accepts this view. 
Budge (1872) investigated the subject experimentally. He 
exposed the ureters in dogs and injected water through them 
into the bladder under such a pressure that it escaped through 
the urethra. This escape through the urethra ceased at once 
when Budge stimulated the muscular fibres of the pars pros- 
tatica and membranacea by means of electricity. If the 
urethra was divided immediately behind the prostate and the 
ostium vesicale stimulated, the escape of water was not 
checked. Dittel (1872) contradicted Budge's statements in 
view of experiments conducted by Strieker and himself, but 
the contradiction is merely apparent. Budge divided the 
urethra from the bladder "immediately behind the prostate," 
i.e., together with the internal sphincter which belongs to the 



32 Blenorrhoea of the Sexual Organs. 

prostate. He then found that electrical irritation of the 
vesical orifice did not prevent the flow of urine. Dittel divided 
the prostate in its posterior third about two lines in front of 
the internal sphincter, and then found that the outflow of 
urine was inhibited by stimulation of the vesical orifice and of 
the adjacent internal sphincter. He concludes, therefore, that 
the internal sphincter may prevent the evacuation of the 
bladder up to a certain pressure, a fact which was not denied 
by Budge. The internal sphincter belongs anatomically to 
the prostate, i.e., to the urethra. Hence, the bladder pos- 
sesses no special sphincter, the escape of urine is prevented 
solely by the contraction of the urethral muscular tissue. 
The bladder is not closed against the urethra, it has no power 
of preventing the entrance of solids or fluids which have 
passed the urethral sphincters or are pressed by the latter 
against the bladder. This fact is very important in regard 
to the diagnosis and pathology of urethral gonorrhoea. 

When empty, the bladder, on account of the tonus of its 
muscular tissue, forms a tensely contracted sphere whose 
mucous membrane is everywhere in contact, so that it possesses 
no lumen or a very slight one. The pars prostatica also pos- 
sesses no lumen on account of the tonus of its smooth muscular 
fibres. The bladder hangs upon the pars prostatica as upon 
a pedicle ; there is a sharp boundary between the bladder and 
urethra. This configuration is not changed when the bladder 
begins to fill with urine (Plate II. Fig. 2). The pars prostat- 
ica remains closed, the bladder dilates and becomes more and 
more spherical, in proportion as the urine enters, an equilib- 
rium being maintained between the pressure of the fluid 
within the organ and the tonic pressure of the muscular layer 
which is striving to contract. The fluid, being subject to this 
general tonic pressure of the muscular coat, is pressed against 
the orifice of the urethra, but this pressure can yet be over- 
come by the tonus of the internal prostatic sphincter and that 
of the elastic ring at the ostium vesicale. But as the disten- 
tion of the bladder increases the pressure exerted by the fluid 
upon the ostium vesicale also increases, and finally becomes 
so considerable that it first overcomes the elasticity of the 
ostium and then the tonus of the internal prostatic sphincter, 
dilates the latter, and the fluid then begins to enter the pos- 
terior part of the pars prostatica. The hitherto sharp 



hmgei 



Plate 





Fig. 2. 



Fi£. 3. 




Blenorrhcea of the Sexual Organs. 33 

boundary between the bladder and urethra is abolished at this 
moment, the transition because a gradual one, and a " neck 
of the bladder " is formed. 

The moment of entrance of the first drops of urine into the 
pars prostatica is also the time at which we feel the first desire 
to urinate. This desire is called forth by the irritation exer- 
cised by the urine upon the mucous membrane of the pars 
prostatica. There is absolutely no reason to believe that this 
desire can be stimulated from any point of the bladder, nor is 
this assumption justified by examination of the wall of the 
bladder with sounds and electricity, nor by our experience 
with patients, especially those suffering- from calculi. All physi- 
ological and clinical experience shows that the pars prostatica, 
when irritated in any way, gives rise to the desire to urinate. 
Thus we know that this desire is violently produced during 
the introduction of bougies into the urethra as soon as they 
pass through the prostatic portion. All diseases of the pros- 
tate are accompanied by the most distressing vesical tenesmus. 
Examination of the prostate per anum and pressure upon it, 
even when normal, causes the feeling of a desire to urinate. 
Injection of a few drops of a solution of nitrate of silver, touch- 
ing and cauterization of the pars prostatica through the endo- 
scope, always causes violent, often long-continued tenesmus. 

The first desire to urinate, which is caused by the stimulus 
of the entrance of the first few drops of urine into the pros- 
tatic portion, can be overcome voluntarily by innervating the 
transversely striated muscular fibres of the external vesical 
sphincter and compressor. As the feeling intensifies with the 
increase in the amount of urine, it can only be overcome by the 
action of the entire perineal muscular layer, and the urethra 
as well as rectum become closed spasmodically. This is the 
reason that when there is violent rectal tenesmus, micturition 
alone is impossible, because every attempt to relax the sphinc- 
ter vesicae externus and compressor also gives rise to relaxa- 
tion of the anal sphincters. 

The urine which now collects will no longer remain in the 
bladder alone but will also accumulate in the pars prostatica, 
which takes a share in the enlargement, and the bladder 
assumes a pyriform shape more and more (Plate II, Fig. 3). 
The pressure of the fluid in the bladder will increase with the 
3 



34 Blenorrhoea of the Sexual Organs. 

amount of fluid, and the increasing- irritation experienced by 
the pars prostatica increases the desire to micturate. 

On account of this inclusion of the pars prostatica in the 
bladder the urethra is considerably shorter when the bladder 
is full than when it is empty, a fact which I have demonstrated 
experimentally. If, in an individual who as yet experiences no 
desire to urinate, an elastic catheter is introduced into the 
urethra until the first drops of urine begin to flow and then 
the length of the portion of the catheter situated within the 
urethra is measured ; and if the same procedure is repeated in 
this individual when the bladder is full and the desire to mic- 
turate already present, it will always be found that in the 
latter case the catheter need be inserted 2 to 3 cm. less deeply 
before the urine begins to flow — in other words, the urethra is 
so much shorter when the bladder is full. Repeated experi- 
ments, which I performed, as a matter of course, upon healthy 
individuals, showed that the length of the portion of the 
catheter within the urethra when the bladder was moder- 
ately full and the desire to urinate absent was 18 to 21 cm., 
when the bladder was very full and the desire to urinate pro- 
nounced, the length was only 16 to 19 cm. While, therefore, 
the internal prostatic sphincter closes the bladder when the 
latter is empty or only moderately full, this function is per- 
formed by the external prostatic sphincter and compressor 
partis membranaceae when the organ is full. 

The fact that the internal sphincter does not constantly 
close the bladder, but only when it is empty or moderately 
full, and that it is unable to resist the pressure of the contents 
of the bladder when the latter is full, and that the external 
sphincter and compressor then assume the function of closing 
the bladder, has been emphasized by various writers. Hyrtl 
said, in discussing micturition : " With this increase in the 
tension of the detrusor, the moment arrives at which its force 
is equal to that of the sphincter. Before this time arrives, 
the organism is unconscious of the desire to urinate. It is 
only when there is an equilibrium between the detrusor and 
sphincter, that the gravity of the urine comes into play. Its 
beginning entrance into the urethra then calls into play the 
contraction of the compressor urethrse, which compresses the 
membranous portion. Then the latter alone retains the urine 
by the compression of the sides of the urethra." 



Blenorrhoea of the Sexual Organs. 35 

The same opinion is also maintained by Antal (1888) and 
Ultzmann (1880). The latter quotes the following description 
by Esmarch: "After a sufficient amount of urine has accu- 
mulated in the bladder and the latter is distended, this dis- 
tention exercises an irritation upon the peripheral ends of the 
sensory nerves of the viscus. The latter pass through the 
spinal cord to the brain, where they produce the sensation of 
" full bladder." If the bladder is still further distended, reflex 
contractions of the detrusor are excited. The contracting 
detrusor gradually overcomes the internal sphincter and 
some urine then enters the neck of the bladder. As soon as 
the urine has entered the neck of the bladder, the external 
sphincter and the compressor urethras contract, partly in a 
reflex manner, partly voluntarily, and prevent the further 
advance of the urine. At this moment arises the feeling of 
the desire to urinate. If the external sphincter is then relaxed 
by the will, the urine escapes in a full stream." Born (1887) 
examined the question experimentally. He injected plaster 
of Paris through the ureter into the empty bladder and al- 
lowed it to set, in animals and in corpses during rigor mortis. 
If only a little was injected and under slight pressure, the in- 
ternal sphincter remained closed and the plaster cast of the 
bladder was ovoid. If more was injected and under greater 
pressure, the plaster extended into the prostatic portion, 
which was occluded by the external sphincter. The cast of 
the bladder was then pear-shaped, the tip corresponding to the 
dilated pars prostatica, which was included in the bladder. 

By experiments on curarized animals, M. v. Zeissl (1892) 
proved that the detrusor and internal sphincter possess an 
antagonistic innervation, i.e., irritation of the same nerve 
fibres causes contraction of the detrusor and relaxation of the 
sphincter, while irritation of other nerve fibres causes con- 
traction of the sphincter and relaxation of the detrusor. If 
these conditions also obtain in man, the internal sphincter 
will be unable to offer any notable resistance to the detrusor, 
because irritation of the fibres which cause contraction of the 
detrusor will also open the internal sphincter. 

We must be cautious, however, in the direct application of 
experiments on animals to the human subject. In the first 
place, the anatomical conditions of the two are different. For 
example, the dog possesses a strong sphincter in the prostate, 



36 Blenorrhcea of the Sexual Organs. 

but the voluntary muscle which in man surrounds the mem- 
branous portion is wanting. In the dog" the membranous 
portion is really a pars nuda. 

This also corresponds to the fact that micturition is en- 
tirely different in man and animals. In the latter it is always 
involuntary, a purely reflex act. 

In infancy, micturition is also a purely reflex act. In the 
child the closure of the bladder is effected only by the invol- 
untary internal sphincter; the child has not yet learned to 
innervate the voluntary muscular fibres of the external 
sphincter and compressor, and employ them in closure of the 
bladder. It is only after education and practice that he 
learns to employ the voluntary muscles, so that gradually 
the unconscious reflex act is converted into the conscious vol- 
untas act. 

In view of all these statements three facts become evident: 

1. The external sphincter materially exceeds the internal 
sphincter in power of resistance, inasmuch as it can resist the 
pressure of the urine to which the internal sphincter was 
compelled to yield. 

2. With a full bladder, from the moment that the desire 
to urinate becomes noticeable, the urine collects not alone in 
the bladder, but also in the pars prostatica, and the bladder 
becomes more and more pyriform. 

3. The pars prostatica contains nerve terminations which 
possess a specific sensibility and which convey the feeling of 
the desire to urinate; under physiological conditions, as the 
result of the pressure of the urine in the pars prostatica; under 
pathological conditions, as the result of various causes (me- 
chanical, chemical, inflammatory). 

The importance of these considerations in regard to the 
pathology of urethritis will be discussed at a later period. 

The compressor partis membranaceae presents still further 
interest. 

In the first place it plays an essential role in the, in part, 
physiological phenomenon which is usually known as urethral 
spasm. 

If, in a healthy individual with a healthy urethra, a sound 
corresponding to the calibre of the urethra, i.e., about No. 24 
Charriere, is introduced, the bulb can usually be reached 
without any obstruction, but on passing into the isthmus 



Blenorrhcea of the Sexual Organs. 37 

urethree, the pars membranacea, this is felt to contract in front 
of the instrument and to close tightly around it, and thus 
impedes the passage of the sound. The irritation which the 
sound exercises on the urethral mucous membrane causes a 
reflex contraction of the compressor partis membranacese. 
In nervous, irritable individuals this contraction may become 
really spasmodic and may make the further passage of the 
instrument impossible. We then speak of urethral spasm. 
Such a spasm may also occur when the mucous membrane of 
the urethra is in a condition of increased irritability as the 
result of inflammatory conditions, and in both cases the spas- 
modic contraction may be so violent that we are readily in- 
clined to believe in the presence of a stricture. If smaller 
sounds are now introduced, their thinner and therefore more 
irritating tip will increase the spasm still more. This spasm 
may also be excited from behind, from the mucous membrane 
of the prostatic portion. This may happen in a perfectly 
healthy individual if, when the bladder was very full, he 
was compelled for a long time to overcome the desire to 
urinate and therefore to innervate the muscular fibres of the 
external prostatic sphincter and the compressor urethras. 
When finally the moment for the possibility of micturition 
arrives, this does not occur promptly in many cases, at least 
in the beginning, and the urine is discharged in a thin, inter- 
rupted stream. The high pressure of the urine in the pars 
prostatica irritated the latter, and the irritation provoked 
reflex contraction of the sphincter apparatus, which only sub- 
sides pari passu with the diminution in the amount of urine 
and its pressure, i.e., with the diminution in the intensity of 
the irritation exercised upon the mucous membrane of the 
pars prostatica. 

Such a reflex spasm of the sphincters is naturally produced 
much more readily when the pars prostatica is in a condition 
of increased irritability as the result of inflammation. In 
severe inflammations the mere irritation of the stream of urine 
is sufficient to produce partial or complete contraction of the 
sphincters and thus narrowing of the stream of urine or re- 
tention, as is seen not infrequently in blenorrhagic processes. 

In all these reflex spasms, whether produced by pathologi- 
cal or physiological processes, the compressor partis mem- 
branaceae is mainly affected, and they therefore occur 



38 Blenorrhcea of the Sexual Organs. 

particularly in the membranous portion of the urethra. In 
rare cases of extreme nervous or inflammatory irritability of 
the urethral mucous membrane, reflex contractions of smooth 
muscular fibres in the submucous tissue of the pars cavernosa, 
and therefore slight spasms may be produced. These inter- 
fere with the introduction of the sound or impede its advance. 
Reflex spasms of the musculus compressor partis mem- 
branaceae may be provoked, not alone by the irritation of a 
sound or bougie but also by the irritation and pressure of 
fluids. And thus we can usually succeed in injecting inert 
fluids into the urethra as far as the bulb, but their entrance 
into the membranous portion is prevented by the contraction 
of its muscular layer. This reflex contraction becomes more 
intense when the injected fluids are slightly irritant, such as 
astringents, and when the mucous membrane in question is in 
a condition of increased irritability as the result of inflamma- 
tion. The contraction of the compressor partis membranacese 
is usually the cause of the fact that the fluids injected into the 
urethra for the treatment of acute urethritis enter as far as 
the bulb but not to the membranous and prostatic portions. 
Attention was called to this experience by Baumes (1840), 
Behrend (1848), Sigmund (1852), Diday (1859), Milton (1875), 
Guiard (1884), Bedoin (1886) and many others. Teleki 
(1891) demonstrated experimentally that, with the ordi- 
nary clap syringe, fluids injected into the urethra only 
reach the bulb, but do not enter the membranous and pros- 
tatic portions. In thirty-five cases he introduced powdered 
methyl blue, by means of the endoscope, into the membranous 
portion. He then injected water into the urethra with the 
clap syringe. The water escaped uncolored from the urethra, 
thus proving that it had not been in contact with the methyl 
blue. In a second series of experiments (twenty cases) he 
injected a concentrated solution of sugar into the urethra. 
The bulb and pendulous parts were then wiped clean through 
the endoscope and the individual allowed to micturate. The 
urine was always found to be free from sugar. From experi- 
ments on the dead body M. v. Zeiss! maintained the possi- 
bility of injecting fluids into the bladder by means of the clap 
syringe, but it must be remembered that we have to deal with 
reflex processes which cannot be studied in the dead body. 
We should also remember the difficulty often experienced in 



Blenorrlioea of the Sexual Organs. 39 

filling- the bladder, during lithotripsy, by applying the syringe 
to the external meatus, despite profound narcosis of the pa- 
tient. It is evident that the external sphincter will finally 
yield to forcible pressure, but this procedure is so violent that, 
with Desnos (1888) we must utter an urgent warning against 
its performance. In addition this requires a larger amount 
of fluid than is held by the ordinary syringe. 

The musculus compressor partis membranaceae, accord- 
ingly, divides the urethra into an interior open and a posterior 
closed portion. But in the same way that this muscle prevents 
the passage of fluid from the anterior into the posterior portion, 
it also prevents the escape of fluid from the posterior into the 
anterior part. If such fluids are to be discharged they do not 
pass externally through the anterior part, but pass backwards 
into the bladder. Thus, blood and pus flow from the pars 
posterior back into the bladder, as do the fluids which we in- 
ject into the pars posterior. Diday (1839) proved this in a 
very ingenious way. If, in a healthy individual, a catheter 
is introduced into the slightly filled bladder until the urine 
begins to flow, the eye of the catheter is situated at that 
moment in the most posterior portion of the pars prostatica 
in front of the internal prostatic sphincter. To the outer 
end of the catheter is now attached a syringe containing about 
3 j. of a lukewarm, perfectly bland fluid, and this fluid is 
slowly injected, the catheter being- slowly withdrawn at the 
same time. We will then find that the fluid, which is thus 
injected into the pars prostatica, does not escape alongside 
the catheter (which we may purposely choose of small size, 16 
to 18 Charriere) but passes into the bladder. So long as the 
eye of the catheter remains behind the compressor, all the 
fluid passes through the pars posterior- into the bladder. On 
further withdrawal of the catheter the moment arrives in 
which it is difficult to inject any fluid at all. This happens 
when the eye of the catheter, in passing through the com- 
pressor, is closed by its spasmodic contraction; a moment 
later, when the eye of the slowly withdrawn catheter has 
passed the compressor and reached the bulb, the fluid begins 
to regurgitate alongside the instrument. With the aid of 
Guyon's " instillateur," an instrument with which we will 
become acquainted in the discussion on the treatment of 
urethritis, Jamin (1883) injected small amounts of fluid into 



40 Blenorrhcea of the Sexual Organs. 

the pars anterior and posterior, and states that when only 
two to three drops of inert fluid were injected into the bulb 
they made their appearance at the orifice of the urethra, while 
he could inject even forty drops in the posterior part behind 
the compressor, without a single drop appearing at the orifice. 
In order to demonstrate the regurgitation of small amounts 
of fluid from the pars posterior into the bladder, Casper (1887) 
deposited a few drops of yellow ferro-kalium cyanate into the 
pars posterior and, at the end of a little while, directed the 
patient to urinate at three intervals. None of the salt escaped 
at the orifice of the urethra. If it had remained in the pars pos- 
terior the first portion of urine would have washed away the 
greater portion, the second portion would have contained only 
traces, and the third part would have been almost entirely free. 
Examinations of the urine with ferric chloride (Berlin blue re- 
action) showed the salt in all three portions of urine, but es- 
pecially in the second and third portions, which, to judge from 
the change in color, contained almost equal amounts of the 
salt — a proof that a part, at least, must have passed into the 
bladder. 

From all these data it is evident that the compressor muscle 
divides the urethra into two sharply defined portions, which 
we call the pars anterior and pars posterior, a division which 
possesses very material importance in the pathology, symp- 
tomatology and treatment of clap in the male. 



CHAPTER II. 

ACUTE URETHRITIS. 

Infection. 

We have learned that blenorrhoea is a virulent process 
whose virus is the gonococcus, and we therefore recognize only 
one condition as necessary to the production of blenorrhagic 
urethritis as of all blenorrhagic aff ections, viz., the conveyance 
of gonococci in any vehicle, which usually, but not always, 
consists of the mucus or pus derived from another blenorrhagic 
affection. 

Blenorrhagic urethritis can only develop by inoculation 
with gonococci. Its chief source is the transmission of blenor- 
rhagic pus from the sexual organs of the female sex, and there- 
fore coitus with a woman suffering from blenorrhoea of the 
sexual organs is the main source of blenorrhagic urethritis 
in the male. It is an evident conditio sine qua non that the 
woman from whom a man acquires blenorrhagic urethritis, 
must herself suffer from blenorrhoea. That this cannot always 
be proven on confrontation, results from the incomplete ex- 
amination and from the fact that the disease is frequently 
latent and presents no symptoms in the female. This is 
especially true of chronic blenorrhoea. The fact that several 
men may acquire blenorrhoea from the same woman while 
others escape, that a man cohabits with a woman safely for a 
long time and then suddenly acquires blenorrhoea, although 
no changes have occurred in the woman, only proves that 
infection does not always take place, but that other conditions, 
favorable to infection, must be present. In their absence, or 
when conditions arise which antagonize infection, the latter 
will not take place. Blenorrhoea of the sexual organs in the 
female is therefore the most important source of blenorrhagic 
urethritis in the male, and coitus is the means of infection. 
Women who are more exposed to the acquisition of blenorrhoea 



42 Blenorrhcea of the Sexual Organs. 

because they bestow their favors upon a number of men, are 
also more dangerous as regards the transmission of clap. Ac- 
cording- to Fournier's statistics (1866) infection was conveyed 
in 387 blenorrhoeas in men by: 

Prostitutes, public, 12 

" private, 44 

Mistresses, Actresses, . . . . . .138 

Working women, 126 

Servants, 41 

Married women, . . . ... . .26 

387 

We see from these statistics that those women who are 
prostitutes without being under police control, do most towards 
the propagation of blenorrhoea, married women less, because 
they suffer less frequently, prostitutes little, because although 
they are often infected, the control and treatment rapidly 
make the infection harmless. 

We have said that coitus is the chief agent in infection, but 
blenorrhoea can also be conveyed in other ways. For example, 
by unnatural sexual intercourse. Thus, Horand (1886) reports 
the following case: A medical student, previously perfectly 
healthy and never infected with blenorrhcea, had intercourse 
per os with a prostitute, but avoided other modes of sexual con- 
tact. A few days later pruritus of the orifice of the urethra 
was experienced, and a typical urethritis developed, in whose 
secretion numerous gonococci were demonstrated. Inasmuch 
as the genitalia as well as the buccal mucous membrane of 
the woman were found healthy on examination, Horand 
assumes that the gonococci were deposited in the girl's mouth 
during a previous coitus per os with a man suffering from 
blenorrhcea and were conveyed in this way. Langlebert, 
Clerc and Diday report similar cases. 

Coitus per rectum may also convey blenorrhcea. Jullien 
(1886) relates that two friends had sacrificed to the same god- 
dess. Orestes, who was to begin the sacrifice but knew him- 
self to be unclean, would not, for the world, soil the sanctuary 
which Pylades was to enter after him. In order to avoid 
betraying either his secret or his friendship, he sacrificed to 
Venus Kallipygos. Pylades, who knew his friend's supposed 



Blenorrhoea of the Sexual Organs. 43 

secret but was ignorant of his tender consideration, thought 
it was more prudent to deviate from the usual custom and 
sacrificed at the same altar as his friend. Orestes had long- 
been consoled, while Pylades still shed abundant tears. Win- 
slow (1886) reports an epidemic of urethral blenorrhoea which 
broke out in a boys' school: This was spread through peder- 
asty, starting from an imported case of clap. 

The manner in which the infection occurs was much dis- 
cussed in former times. Wendt (1827) maintained that it 
occurred after ejaculation, by a sort of aspiratory activity of 
the urethra, and adduces in evidence the fact that some volup- 
tuaries, who masturbated in lukewarm milk, had discharged 
from the urethra a few drops of milk just before the next 
micturition. Others assumed that the virus is absorbed by 
the glans, received in the urethra in the shape of a gas, sucked 
in before or after ejaculation, or that it only causes irritation 
externally. All these assumptions fall to the ground, since 
we know that direct transmission of the gonococci-containing 
vehicle is necessary to infection. 

Whether contact of this vehicle with the orifice is sufficient 
for infection, or whether its entrance into the urethra, if only 
for a short distance, is necessary, must be left undecided. The 
latter seems more probable. But there are always certain 
factors which favor or interfere with the occurrence of infec- 
tion. We know that not alone the transmission of the virus 
but also the suitable character of the soil is necessary in every 
infection. Even if the first condition is present, the receptivity 
of the soil may vary. In this regard one factor merits special 
consideration. A slightly alkaline soil seems especially adapted 
to the implantation and development of gonococci as of all 
other virulent micro-organisms. The mucous membrane of 
the urethra is always washed by an acid fluid on account of 
the urine which remains upon it. This amount would be suffi- 
cient to cause notable injury, during an ejaculation, to the 
semen, which is extremely sensitive to acids. But the urethra 
possesses special glands, which are particularly active during 
erection, and are designed to neutralize these acids. These 
glands are racemose and are situated in the meshwork of the 
corpora cavernosa. During erection this meshwork and the 
glands enclosed within it are subjected to the pressure result- 
ing from the stasis of blood and distention of the corpus 



44 Blenorrhoea of the Sexual Organs. 

cavernosum. This expresses from the numerous glands a clear, 
gelatinous, alkaline (not acid, as was stated by Sinety and 
Henneguy, 1885) fluid, which covers the mucous membrane of 
the urethra, neutralizes the traces of acid, and may also escape 
from the urethra in the form of drops as urorrhcea ex libidine. 
This alkaline fluid also increases the receptivity for an invasion 
of gonococci, by making the soil alkaline, causing swelling of 
the epithelium, and facilitating the entrance of the germs. 
Hence infection is favored by everything that stimulates the 
secretion of this alkaline mucus. This includes protracted and 
repeated coitus and all factors which retard the occurrence of 
ejaculation, such as bodily strain or drunkenness. This is also 
true of coitus which has been preceded by long-continued 
sexual excitement and the attendant protracted erections, 
which are always accompanied by urorrhcea ex libidine. It is 
questionable whether infection is favored by a wide meatus 
or by the absence of ejaculation, which sweeps away the 
gonococci. 

Among the factors which are unfavorable to infection must 
be mentioned, brief duration of coitus, the absence of repeti- 
tion of the act, and micturition immediately after coitus. The 
latter rapidly acidulates the soil, and thus possibly removes 
the introduced gonococci from the 'membrane or even kills 
them. 

To what extent stimulants, such as spicy food and drink, 
and cantharides, favor infection must be left undecided. At 
all events they may facilitate infection by causing protracted 
erections on account of the increase of sexual desire, and also 
by the stimulus to repeated and artificially prolonged coitus. 

But the production of urethral blenorrhoea requires nothing 
more than the entrance of the gonococci in any vehicle into 
the urethra. And so a clap will result from the introduction 
of a gonococcus pure culture for purposes of experiment or 
in any other way, such as directly through the medium of 
articles of clothing, instruments, etc. We cannot deny the 
development of blenorrhoea in this way, although authentic 
cases of this kind are rare. Among the laity, however, there 
is a remarkable tendency to regard this mode of infection as 
frequent, and to accept the most impossible manner of infec- 
tion rather than to accuse the mistress, or even a prostitute, of 
effecting the infection. 



Blenorrhoea of the Sexual Organs. 45 

Symptomatology. 

The entrance of gonococci into the meatus and perhaps 
also into the front part of the urethra causes an acute catar- 
rhal inflammation of the mucous membrane with a typical 
course, which is known as acute urethral blenorrhoea or clap. 
How far does the disease extend along" the canal ? The older 
physicians did not think that the inflammation involved a 
large surface. For example, Swediaur (1798) believed that 
clap was located chiefly in the fossa navicularis, where it 
attacks the lacunae of Morgagni, while all claps that are 
situated more deeply, at the curve of the penis, the veru 
montanum, neck of the bladder or bladder, resulted from im- 
proper treatment or some internal cause. 

Later observers noticed that clap may extend further along 
the mucous membrane and may even attack the entire canal. 
Behrend (1848), the translator and commentator of Hunter, 
divided blenorrhoea into a blenorrhoea urethralis penis and 
blenorrhoea urethralis prostatica. 

Even previous to this time Desruelles (1836) had gone 
further, and distinguished four kinds of blenorrhoea according 
to its location: 1, Clap of the most anterior portion; 2, clap 
of the pendulous portion; 3, clap of the bulb; 4, clap of the 
membranous portion. This classification, because artificial, 
found no support, and the opinion gradually gained ground 
that clap always extends along the entire urethra, from the 
external to the vesical orifice. Zeissl and Sigmund also advo- 
cated this view. 

But this opinion did not remain unopposed. Langlebert 
(1864) claimed that clap is often confined to the cavernous 
portion of the urethra. Tarnowsky (1872) maintained that, 
in the majority of cases, the process does not extend beyond 
the boundaries of the bulbous portion. The same opinion was 
adopted by Mueller (1875). But it was especially Guyon (1883) 
and his pupil Jamin, who clearly proved the fact that acute 
typical urethritis is confined to the pars cavernosa, that the 
spread of the process to the pars posterior is an ominous com- 
plication, which does not belong to typical urethritis. This 
doctrine was developed on French soil by Aubert (1884), Erand 
(1885), Picard (1885), Bedoin (1886), Crivelli (1886), and trans- 
planted to Germany by Ultzmann (1883), where it is com- 



46 Blenorrhcea of the Sexual Organs. 

bated by only one opponent of note, viz., Fuerbringer (1884). 
We have also become convinced that clap, in its typical course, 
extends to the bulb and no further. The extension of the 
inflammatory process to the pars posterior must be regarded 
as a complication, which produces deviations from the typical 
course, and may be the source of other serious sequelae and 
complications, in other words, which change the symptoma- 
tology materially and aggravate its course. 

The typical form, which extends only to the bulb, we call 
acute anterior urethritis, while the term acute posterior 
urethritis is used when the process extends to the pars pos- 
terior, and thus really over the entire mucous membrane, on 
account of the predominance of the symptoms which result 
from the affection of the posterior portion. 

Acute Anterior Urethritis. 

Acute anterior urethritis is a blenorrhagic inflammation, 
with a typical course, of the mucous membrane of the pars 
cavernosa and bulbosa urethrae. Beginning with slight symp- 
toms after several days' incubation, the process gradually in- 
creases, at first in intensity, then in extent, and reaches its 
acme in both respects at the end of the second or beginning of 
the third week. It then diminishes gradually in intensity and 
extent in the same direction, i.e., from before backwards, and 
terminates in five to six weeks. 

Every blenorrhoea begins with a 

Period of incubation, i.e., if an individual has been exposed 
to infection, the first symptoms do not occur immediately 
afterwards, but an appreciable interval of apparent perfect 
health, which is known as incubation, intervenes between 
infection and the first symptoms. This incubation is explained 
on the ground that the virus is conveyed in extremely small 
quantities, and in the beginning produces very slight symp- 
toms which can neither be seen nor felt. But the virus 
animatum, having reached a favorable soil, increases rapidly, 
and the evidences of reaction increase in the same measure, 
until finally they reach the bounds of the visible. The incuba- 
tion then ceases. The length of this period varies between 
quite considerable limits, and its determination is often made 
difficult by the uncertain and false (intentionally or otherwise) 
statements of the patient. 



Blenorrhcea of the Sexual Organs. 



47 



The following is the duration of incubation as shown by the 
statistics of 479 cases by Eisenmann (1830), Hacker (1850) and 
Hoelder (1851) : 



1 day 


in 


2 days in 


3 


a 


a 


4 


a 


a 


5 


a 


a 


6 


a 


a 


7 


a 


a 


8 


a 


a 


9 


a 


a 


n 


a 


a 



11 cases 
59 " 

126 " 

62 " 
49 " 
10 « 

63 " 

12 " 
12 " 
23 " 



12 <( 


3 111 
tt 




13 •< 


ft 




14 " 


it 




19 " 


it 




20 « 


it 




30 w 


ft 




Uncertain in 





6 cases 



6 


a 


19 


n 


2 


a 


1 


it 


1 


tt 


9 


it 



479 



Lanz's (1893) more recent statistics, which are important 
because the nature of the disease was proven in every case by 
the demonstration of the presence of gonococci, gives the fol- 
lowing results: 



1 day in 


. 


2 


cases 


8 


days in 


. 


1 case 


3 days in 


. 


15 


tt 


10 


a 


a 


. 


1 " 


4 a tt 


. 


4 


a 


14 


tt 


a 


. 


1 " 


5 " " 


. 


9 


a 


20 


a 


a 


. 


2 cases 


fi a a 


, 


4 


it 










— 



39 

In Welander's (1886) cases of gonorrhoea, which were pro- 
duced artificially by inoculation with pus containing gonococci, 
the period of incubation was two days. It also varied from 
two to three days in the inoculations of Bumm (1885), Anfuso 
(1891), Wertheim (1892), and our own. 

The greatest number of cases develop, therefore, on the 
third day, more than two-thirds within the first week (380 out 
of 479) ; a period of incubation longer than fourteen days is 
extremely rare. 

In truth, the duration of the period of incubation varies, as 
a rule, between three and five days. It is usually shortest 
after a first infection, and generally becomes somewhat longer 
after subsequent infections, but it rarely exceeds six or seven 
days. 

Extremely short periods of incubation, such as twenty- 
four hours or less, are very suspicious. It is particularly sus- 



48 Blenorrhcea of the Sexual Organs. 

picious as regards the question whether we have to deal, not 
with a fresh infection, but with a previous, apparently cured 
clap, which ran a latent course for a longer or shorter period 
and exacerbated on account of recent coitus, the exacerbation 
being regarded as a fresh infection. 

Nor should statements concerning long periods of incuba- 
tion be accepted without further inquiry. In such cases it 
usually happens that infection resulted from coitus performed 
a longer or shorter period before, and this was followed by 
subacute urethritis, which was overlooked by the inattentive 
patient. An excess in Baccho or some other noxious agent 
then brought the process to its complete acute development and 
this impressed the patient as the beginning of a fresh disease. 
It is also evident that the conduct of the patient in other re- 
spects will also influence the duration of incubation. Atten- 
tion and sensitiveness on the one hand, recklessness, inatten- 
tion and slight sensitiveness on the other hand, will cause the 
first morbid symptoms to be noticed sometimes earlier, some- 
times later. 

The period of incubation is important in so far as it draws 
a sharp line between virulent blenorrhcea of the urethra and 
all those catarrhs which, symptomatically like blenorrhcea, 
owe their development to mechanical and chemical influences 
and which develop immediately after such action, so that a 
period of incubation is absent. Thus, if a catheter or bougie 
is introduced into the urethra of a perfectly healthy individual 
and a sharply astringent or caustic injection is made, a puru- 
lent secretion, accompanied by inflammatory symptoms, will 
appear. Apart from the absence of gonococci this will be 
characterized by the fact that it begins at once or a few hours 
after the injection. 

The transition from the period of incubation to the morbid 
process forms a longer or shorter 

Prodromal Stage. — The patients experience a slight tickling 
or pricking at the orifice, both spontaneously and on urination, 
the orifice appears somewhat reddened and, if urine has not 
been passed for some time, the lips of the meatus are glued 
together, or a viscid, slightly grayish fluid appears between 
them in the shape of a small drop. In sensitive individuals 
slight general symptoms — depression, malaise, anorexia — 
occur at this time. These are probably of a psychical char- 
acter, the result of a premonition of the things to come. 



Blenorrhcea of the Sexual Organs. 49 

The prodromal symptoms are rapidly aggravated and pass 
into the 

Florid Stage. — The mucous secretion at the orifice increases, 
but is gradually converted into a, at first, milky, then creamy 
pus. In a short time, usually at the end of the first week or 
beginning of the second week, thick green pas appears, and its 
amount soon becomes so considerable that it exudes day and 
night in the form of large, heavy drops, and soils the genitalia 
and clothing of the patient. The inflammatory phenomena, of 
which the suppuration is a symptom, increase to an equal 
degree. The meatus and surrounding parts are reddened, the 
course of the entire urethra in the pendulous portion is swollen 
and tender on pressure; lancinating pains occur spontaneously, 
but are especially violent during erections. The latter are 
particularly frequent at night and extremely distressing to the 
patient. This is also true not infrequently of pollutions. On 
account of the swelling of the urethral mucous membrane, the 
stream of urine becomes very narrow^ divided and split up, 
and the passage of urine along the urethra is extremely painful 
and attended by more or less intense burning along the 
canal. All these symptoms increase until the end of the 
second week or beginning of the third week. At this time the 
inflammatory process has extended to the bulb. Pressure, and 
a feeling of warmth and fullness in the perineum, are added to 
the other symptoms, and their severity, together with the 
slight nocturnal rise of temperature and the insomnia due to 
the painful erections, reduce the patients, mentally and physi- 
cally, not a little. 

At this time — about the middle or end of the third week — 
the symptoms usually undergo a rapid change for the better 
in typical cases of acute anterior urethritis. The inflammatory 
phenomena and the subjective symptoms diminish, the secre- 
tion, although still profuse at first, becomes thinner and milky, 
later mucous, then diminishes in amount, and is reduced to a 
small amount of grayish mucus which glues together the lips 
of the meatus and is visible only in the morning. Finally, this 
disappears and the entire process may have undergone re- 
covery by the fifth or sixth week after infection. 

In severe cases deviations from the course just described 
may take place, inasmuch as, after the acme (third week) the 
inflammation spreads to the pars posterior, or after the ter- 
minal stage the process passes into a chronic stage. 
4 



50 Blenorrhcea of the Sexual Organs. 

In milder cases, especially under the favorable hygienic and 
dietetic conditions to which hospital patients are subjected, 
the process may be materially shortened without any other 
than, at the most, antiphlogistic treatment, because the proc- 
ess does not occupy its entire territory, but is confined to a 
portion of the pars pendula, and without attaining- its full 
development is completely cured in two to three weeks. 

Even when the course is perfectly typical the intensity of 
the process varies extremely in different cases. Moderate 
suppuration, mild subjective symptoms consisting- of slight 
burning during micturition and slight pain on erection, — and 
abundant, even sanguino-purulent secretion, almost constant 
pains, increasing very considerably on urination and erection, 
and not inconsiderable general symptoms, are the extremes. 
As a rule, the first infection is the most intense, later ones are 
milder; they rival the first attack in severity only when oc- 
curring at intervals of several years. As a matter of course 
the virulence of the conveyed secretion plays a part which 
should not be underestimated. 

We will now consider the individual symptoms somewhat 
more in detail. 

Inflammatory Symptoms. — If we examine the patient's 
genitals we will find, in mild cases, merely a slight redness of 
the orifice and the surrounding parts. The mucous mem- 
brane of the meatus is somewhat everted, as the result of the 
swelling, reddened, and covered with crusts of dried pus. In 
the severer cases the swelling is more pronounced, and is not 
confined to the vicinity of the orifice; the entire glans penis is 
swollen, reddened and in a condition of semi-erection. The ec- 
tropion of the mucous membrane is more marked, and the 
latter is excoriated and bleeds readily. The prepuce is cede- 
matous, but has the normal color ; or it may also be reddened, 
and the redness and swelling then extend more or less to the 
integument of the penis. Beneath the skin we not infrequently 
see and feel one or more strands, partly cylindrical, partly 
spindle-shaped, which may attain the thickness of the little 
finger. These are painful on palpation and may be traced to 
the symphysis. The integument over them may be still mov- 
able, but it is often adherent to the strands, especially when it 
is also reddened and cedematous. These strands, which often 
take their origin from the frenulum, pass around the coronary 



Blenorrhcea of the Sexual Organs. 5 I 

sulcus in an arch and unite in the median line of the dorsum, 
are inflamed lymphatics (acute lymphangioitis). This affec- 
tion, although very painful — it is attended by painful tension, 
particularly during erection — is a relatively harmless and in- 
significant complication which usually undergoes rapid resolu- 
tion. 

The urethra is more or less swollen along its entire course, 
and pressure upon it is painful, particularly in the region of 
of the fossa navicularis. Along the course of the urethra we 
often feel more or less numerous nodules as large as a millet 
seed, the swollen Littre's glands, which, in very acute cases, 
are often arranged in rows like a rosary. 

After expressing the pus from the pendulous urethra and 
cleansing the lips of the meatus, some gonococcus-containing 
pus may sometimes be squeezed out of openings, as large as 
the prick of a pin, on the inside of the lips of the meatus. The 
blenorrhcea has then extended into the mucous glands or blind 
crypts of the urethra, which are situated in the lips of the 
orifice. Diday (1860) first called attention to this para-urethral 
blenorrhcea, which has been recently studied anew by Jadas- 
sohn (1890). 

The same condition is found in hypospadias, in which the 
pus often escapes not alone from the underlying urethra, but 
also from the two or three blind crypts of the covering of the 
glans; it may also be squeezed out of two para-urethral canals 
which are situated to the right and left of the orifice. 

Similar blind crypts are found in the coronary sulcus at 
the praeputial margin. I have demonstrated anatomically 
that the so-called Tyson's glands are also ciwpts and not true 
glands. These crypts may also be the site of blenorrhagic 
inflammation, as has been shown by Toulon (1889), Pick (1889), 
and Jadassohn (1890). Very obstinate, hard, inflamed nodules 
are then produced ; they suppurate from time to time and then 
close up. The pus contains gonococci. Toulon (1889) calls this 
affection external urethritis, and demonstrated the prolifera- 
tion of gonococci between the pavement epithelium cells, which 
Bumm regarded as immune. I have repeatedly observed the 
external urethritis described by Jadassohn — inflammatory 
strands alongside the raphe of the penis, which usually con- 
tain several small fistulous openings. In one of my cases such 
an inflamed strand extended to the penoscrotal angle. Punc- 



52 Blenorrhoea of the Sexual Organs. 

tate openings formed in various places and discharged pus 
which contained gonococci. An injection, with the hypodermic 
syringe, of weak solutions of corrosive sublimate and carbolic 
acid showed that the fistulous openings communicated with 
one another. Recovery only ensued after slitting the fistulous 
canals, which are permeable to fine sounds. I recently ob- 
served a unique case of blenorrhagic infection of a canal situ- 
ated alongside the meatus, without blenorrhagic infection of 
the urethra. 

Secretion. — This is the most constant, often almost the sole 
symptom of blenorrhoea. It varies according to the stage of 
the process, and the abundance and purulence of the secretion 
are the most important gauge of its intensity. 

The secretion is muco-purulent. Its abundance is propor- 
tionate not alone to the intensity but also to the extent of the 
process. Slight at the onset, the amount increases from day 
to day, reaches its maximum with the acme of the inflamma- 
tory process or somewhat later, and then gradually diminishes. 
It is often ver}^ considerable at the height of the disease. 
When the patient stands before us stripped, the pus not in- 
frequently wells out in drops from the urethra. The amount 
of secretion varies not alone according to the stage of the 
disease, but also according to the time of day. Most patients 
notice that the secretion is greatest in the morning, diminishes 
towards noon and is least at night; it then increases again 
until morning. These variations in the accumulated amount 
of secretion depend in part upon the time allowed for its accu- 
mulation. It will depend evidently on the intervals in which 
the urethra is cleansed of secretion by urination. The fact 
that the patients generally urinate either not at all or only 
once during the night is brought into causal relation with the 
fact that the morning secretion is the most considerable. 
This relation is undeniable, but it is not the only cause of the 
increased morning secretion. Accurate observations have 
shown that in the course of every acute clap nocturnal exacer- 
bations and diurnal remissions alternate periodically. The 
amount of pus found in the morning is always considerable, 
even if the patients micturate between three and four o'clock 
and thus discharge the pus. If they retain the urine five or 
six hours during the day, the accumulation of pus is never as 
great as in the morning. The inflammatory symptoms are 
also aggravated at night. Patients who are constantly in 



Blenorrhcea of the Sexual Organs. 53 

bed, as in the hospital, may sleep quietly for several hours 
during- the day, without being- annoyed by erections, but they 
are hardly asleep at night before they are awakened by an 
erection. 

But these exacerbations and remissions are not so distinct 
in patients who remain permanently in bed. For this reason 
I believe that the nocturnal exacerbation is due in part, 
thoug-h not entirely, to the noxious influences of the day. 

The amount of secretion may be g-aug-ed from that which 
escapes from the meatus, but accurate data concerning- the 
quantity and nature of the secretion are also furnished by ex- 
amination of the urine, which presents essentially different 
appearances in the different stag-es of the disease. 

We will first emphasize, from a diagnostic stand-point, the 
fact that in acute anterior urethritis the production of pus 
takes place in the pars pendula and bulbosa. If the pus is 
produced in larg-e quantity it will escape from the orifice of 
the urethra, and its passage from the bulb into the pars 
posterior is impossible. If a patient who is suffering- from 
anterior urethritis passes urine, the pus accumulated in the 
urethra will be swept away by the first stream, which thus 
becomes cloud} 7 . The urine passed subsequently finds the 
urethra free from secretion and therefore remains clear. If 
we perform Thompson's test with the two glasses, i.e., direct 
the patient to pass the urine in two parts into two beakers, 
the first urine passed alone will contain secretion, the urine in 
the second glass will remain clear. 

The nature and amount of this secretion are shown much 
more clearly by examination of the first urine passed than by 
looking at the secretion as it wells up from the urethra. In 
the prodromal stage the secretion is slight and mucous; it is 
rolled together by the urine, in which it appears in the shape 
of fine or coarse threads, clap threads. The amount of secre- 
tion gradually increases and becomes more purulent, its color 
grows milky. The urine is then more or less cloudy, and if 
allowed to stand, two layers are seen at the bottom of the 
vessel. The lower one is a narrow, firmer layer of pus com- 
posed of small, yellowish-white clumps ; the upper layer is a 
broader, looser, grayish layer of mucus, above which the urine 
itself looks clear. The more purulent the secretion, the more 
the width of the mucous layer diminishes and that of the 



54 Blenorrhcea of the Sexual Organ?. 

purulent layer increases, and in the purulent stage, at a time 
when the abundant secretion is deep yellow or even greenish 
yellow, the sediment, which is usually deposited rapidly, is only 
purulent. As the process improves the purulent secretion 
becomes muco-purulent, then mucous, and diminishes in 
quantity; in the mucous terminal stage we find only a few 
shreds of mucus and pus in otherwise clear urine. 

Microscopical examination of the secretion furnishes inter- 
esting data concerning the morphological constituents and the 
presence of gonococci. 

In the beginning the mucous secretion of the prodromal 
stage or the shreds collected from the urine contain (Plate III., 
Fig. 5) chiefly large, rhombic pavement epithelium and only 
a few pus cells. The gonococci, which are usually present 
in no small numbers, are in great part free, in part are sit- 
uated upon or more rarely within the epithelial cells, and also 
within the pus corpuscles. 

In the stage of muco-purulent secretion, the number of gon- 
ococci first increases, then the pus corpuscles; many pus cells 
are more or less filled with gonococci. Free masses of the 
cocci are rare, and when present they can usually be distinctly 
recognized as derived from the destruction of pus cells which 
had been filled with the organisms. Pavement-epithelium 
cells are scanty and usually more or less covered with gono- 
cocci. Oval, polygonal and cuboid, uninuclear transitional 
epithelium, also partly covered with gonococci, are more 
numerous. 

At the height of the process (Plate III., Fig. 6) all other 
cellular constituents diminish in comparison with the pus cells, 
which are present in large numbers and dominate the field. 
The number of gonococci also seems smaller, although there 
are still a large number of gonococci-containing pus cells. I 
do not think that the number of gonococci diminishes at this 
stage, but the relatively more rapid production of pus corpus- 
cles makes their number appear smaller. Podres (1885) states 
that in one series of cases, at this stage, he found all the gono- 
cocci in pus cells and very few free ones, in a second series of 
cases the majority of the gonococci were free. The first series 
ran a mild, the second a severe course. In the numerous ex- 
aminations which I have made, I have been unable to confirm 
these statements, especially their prognostic significance. 

In the terminal stage (Plate III., Fig. 7), the number of 



Finger 



Plate III. 



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Fin. 5 



f IN 



•u ^> 




\ "VWj .e*,-.< w ji. , 



fay 



Fiq.7 



V ** 

_j5|a w* 



aj 



_ C*m 

- — _/ 



Kg. 8 



ft 


















r^eA* 



Blenorrheea of the Sexual Organs. 55 

gonococci and pus cells becomes smaller, transition epithelium 
cells are numerous, pavement epithelium scanty. The serous 
secretion and shreds of this stage consist mainly of transition 
epithelium, a few gonococci and pus corpuscles. Among the 
transition epithelium are found not a few hyaline, " iodophile " 
epithelium cells (Fuerbringer) which stain rapidly with the 
weakest solutions of iodine. 

In exacerbations after external noxa the number of pus 
corpuscles rapidly increases. It is a striking feature in such 
cases that, before the exacerbation has reached its height, the 
pus cells contain few gonococci, while the epithelium cells, 
which are usually aggregated in numbers, are covered with 
thick layers. 

And thus the microscope furnishes no unimportant data 
concerning the duration of the process. If the orifice is slightly 
reddened and a slight mucous secretion is present, while the 
microscope shows that the secretion consists of abundant flat 
epithelium and numerous gonococci but few pus cells, we have 
to deal w T ith a recent, beginning infection. If, with the same 
symptom complex, the secretion contains numerous transition 
epithelium, few pus corpuscles and gonococci, the process is 
approaching recovery. 

The presence of numerous pus corpuscles and gonococci are 
evidence of the severity of the process, while few gonococci 
make the disease appear milder. But in order to draw any 
conclusion concerning the intensity of the process from the 
number of gonococci, wc must examine a large number of prep- 
arations from the same day. The gonococci are not distributed 
uniformly in the pus, they are more abundant on one slide, less 
abundant on another, so that if we are satisfied with the ex- 
amination of a few slides, we are apt to arrive at the opinion 
that their occurrence is intermittent and variable, while, on the 
whole, the number present in the pus runs quite a parallel 
course to the severity of the process. In the examination we 
should always use the pus which is obtained from the deepest 
part of the urethra by pressure from the outside. Apart from 
the fact that we thus avoid contamination with the bacteria, 
which are always present in the pus of the orifice, we obtain 
the pus from the most recent and freshly inflamed parts. This 
always contains more gonococci than the pus of the anterior 
parts, in which the inflammation has perhaps passed its acme 
at the time of examination. 



56 Blenorrhcea of the Sexual Organs 

Subjective Symptoms. — These are very variable. The 
most frequent and characteristic symptom is pain during uri- 
nation. This varies according- to the degree of inflammation. 
In the beginning it is slight and manifested by a mere feeling 
of warmth during the passage of the urine and for a little 
while afterwards. This is soon converted into a real sensation 
of pain. It is especially at the moment when the first drops 
of urine separate the swollen mucous membrane of the ure- 
thra that a burning pain is felt, at first not violent, but rap- 
idly increasing in severity. At the height of the inflammation 
this feeling is so violent that the patients delay urination as 
long as possible, and hardly drink any fluids in order to avoid 
micturition. The common French term "chaude pisse" and 
the English " burning " owe their use to this symptom. After 
the acme of the inflammation has passed, the pain soon sub- 
sides and disappears long before the suppuration. In excep- 
tional cases the pain may be slight despite abundant, even 
greenish suppuration, while slight suppuration is sometimes 
attended with violent pain. 

The pain is located in the entire pars pendula, but one point, 
usually the orifice or fossa navicularis, more rarely the peno- 
scrotal angle, is generally mentioned as the chief site of the 
painful sensation. In some cases, finally, the pain, which be- 
gan during the acute stage, remains long after the general 
inflammatory symptoms have subsided. 

In addition to the pain on micturition spontaneous pains 
also occur. Before the affection reaches its acme these pains 
are especially distressing, and consist partly of entirely sponta- 
neous, lancinating pains along the pars pendula, partly of 
pains which are produced by pressure, improper position of the 
penis, movement and the sitting posture. In severe cases they 
extend into the testicles, groins and along the seminal ducts, 
and impede every movement of the patient. 

Sexual Irritative Symptoms. — These are hardly ever ab- 
sent in a case of acute urethritis. They begin in the prodromal 
stage and manifest themselves by morbidly increased sexual 
desire, more frequent and vigorous erections, increased impetus 
coeundi. This not infrequently leads to indulgence in sexual 
excesses, which are usually associated with increased voluptu- 
ous sensations. But this condition, which is usually not disa- 
greeable to the patient, does not last long. When the in- 



Blenorrhcea of the Sexual Organs. 57 

flammatory symptoms are fully developed, the increased sexual 
excitability constitutes one of the greatest suffering's of the 
patient. As in the prodromal stage frequent and very vigor- 
ous erections set in, but the swelled mucous membrane of the 
urethra does not answer to the demands for space caused by the 
elongation and broadening of the tensely filled corpora cavern- 
osa; it has lost some of its elasticity. The patients therefore 
complain, at each erection, of a feeling of distention and drag- 
ging of the urethra. If we have the opportunity of examining' 
the rigidly erect penis in this stage, we find not infrequently 
that the meatus and surrounding parts are drawn, in a funnel 
shape, into the urethra by the rigid mucous membrane. This 
feeling of tension increases to one of considerable pain by 
clonic contractions of the ischio-cavernosi and bulbo -cavernosi 
muscles, whose action not infrequently forces the penis, like a 
pendulum, against the abdominal walls. But it is particu- 
larly the moment of ejaculation, during the pollutions pro- 
voked by the sexual irritation, that is attended by violent 
pain. If the inflammation and sexual irritation are violent, 
the intense erections and the consequent ejaculation of semen 
may produce direct ruptures of the mucous membrane, hem- 
orrhages, and thus a bloody color of the pus and semen — a 
condition which is known as Russian clap. 

The sexual irritation is constant. Every external influence 
which stimulates the sexual sense may produce erections very 
quickly in patients in this condition, even when normally of a 
cold disposition. The erections are especially provoked by the 
heat of the bed. Hardly has the patient, who is usually filled 
with dread of the coming night, gone to bed and fallen asleep, 
when the first erection ensues and he is rudely awakened by 
the pain. When walking on the cold floor, the application of 
cold compresses, etc., have relieved the erection and the patient 
again retires, the erection appears anew and the night is thus 
full of misery. 

Not infrequently the erections are constant and last for 
hours or half a day. If the corpus cavernosum urethras, on 
account of the swelling of the urethral mucous membrane, 
cannot follow the increase in size of the corpora cavernosa 
penis, this gives rise to deformity in the shape of the organ. 
In the mildest grade the glans alone is bent downwards (this 
was called " un gland arque" by Ricord); in the severer forms 



58 Blenorrhoea of the Sexual Organs. 

the entire penis assumes an arched shape, with the concavity 
downwards. This is the condition known as chorda venerea. 
In contrast to the inflammatory chordee due to inflammatory 
irritation of the corpora cavernosa, this is also known as spas- 
modic chordee, because some observers, such as Milton, Koel- 
liker and Hancock, do not regard it as a purely passive 
process, due to diminution in the elasticity of the urethral 
mucous membrane, but as a spasm of the longitudinal fibres 
of the smooth muscular layer in the submucous tissue of the 
urethra. 

Chordee is one of the most distressing" symptoms of acute 
urethritis. The pain explains the brusque manner in which 
the patients endeavor to rid themselves of it, by placing the 
curved and erect penis upon a hard substance and endeavor- 
ing to straighten it by a blow of the fist. Breaking chordee 
in this manner is an extremely old custom. Abu Oseiba men- 
tioned it in 940 a.d. This practice is usually disastrous to the 
patient. The violent injury generally causes rapture of the 
urethra with violent hemorrhage, perhaps folloAved by inflam- 
mation of the corpora cavernosa, or at least by cicatricial 
stricture of the urethra after recovery. Paul (1875) and 
Jullien (1886) mention such cases. Voillemier lost a patient 
from the hemorrhage. One of Dufour's (1854) patients per- 
formed coitus when suffering from chordee. Severe hemor- 
rhage set in afterwards, the penis became swollen, ecchymoses 
in the skin appeared, and dysuria set in. Despite vigorous 
antiphlogosis, gangrene of the penis set in, cystitis and death 
after typhoid symptoms. The autopsy showed ammoniacal 
cystitis with ulcerations, pyelit s, and suppurative nephritis; 
the urethral mucous membrane was torn 3 cm. and 6 cm. from 
the orifice, the lower rupture led into a gangrenous cavity. 
Similar symptoms may also occur after chordee without ex- 
ternal injury. Villeneuve (1873) reports a case in which chor- 
dee was followed by gangrene, and this by pyaemic symptoms, 
phlebitis of the prostatic plexus, metastatic abscesses in the 
liver and lungs, and death. 

Disturbances of the Discharge of Urine and Semen. — The 
notable diminution of elasticity, associated with swelling of the 
urethral mucous membrane, causes disturbances in the dis- 
charge of urine and semen. The swelling of the mucous mem- 
brane produces narrowing of the lumen, which becomes so much 



BlenorrJicca of the Sexual Organs. 59 

more evident because the patient does not employ abdominal 
pressure on account of the pain. The urine is therefore evac- 
uated in a narrow, feeble stream, which, when the pain is great, 
is often interrupted on account of the reflex contractions of 
the compressor urethras. When the inflammatory symptoms 
are pronounced, the irritation of the first drops of urine may 
be so intense that reflex contraction of the compressor occurs 
at once and continues spasmodically for some time. True 
dysuria may develop, inasmuch as this spasm occurs with every 
attempt at micturition. The diminution in the elasticity of 
the swollen urethra is also a cause of the insufficient move- 
ment and slow discharge of the urine, but it is especially the 
last drops in the rigid tube formed by the swollen mucous 
membrane which remain behind and only escape gradually. 
Incontinence is thus a not infrequent symptom of urethritis. 
Ejaculation is impeded in the same way, and the semen escapes 
slowly and drop by drop from the urethra. 

General Symptoms. — Blenorrhcea, however severe, always 
remains a local disease. Nevertheless its acute stage is always 
accompanied by a series of usually mild general symptoms. 
Slight chilliness, fever of slight grade (rarely over 38°), malaise, 
anorexia and mental depression develop. The appearance of 
the patient usually suffers; he has a sallow, yellow complex- 
ion, and the sunken eyes, with rings around them, disfigure 
the hitherto healthy and robust individual. Many of these phe- 
nomena are the result of psychical factors, the insomnia due 
to the sexual irritation, and the changed mode of life, espe- 
cially the abstinence from alcoholics. But these factors do not 
explain the general symptoms entirely. The direct migration 
of gonococci into the blood is hardly conceivable, but it can- 
not be denied that the vital processes carried on by the cocci 
in the urethral mucous membrane may produce chemical sub- 
stances (ptomaines) which pass into the circulation and pro- 
duce a toxic effect. 

Course. — The regular course of acute anterior urethritis 
as just described is not observed in all cases, and it might even 
be regarded as exceptional. 

In the typical course a period of incubation of three to five 
days is followed by a prodromal stage of hardly two days. 
The then beginning blenorrhagic process increases in severity 
for about fourteen days, reaches its acme in the third week, 



60 Blenorrhcea of the Sexual Organs. 

and recovers at the end of two to three weeks, the entire 
process thus lasting- five to six weeks. There may be varia- 
tions, however, in every stage of the disease. 

The period of incubation may be somewhat shorter or 
longer; the prodromal stage is less subject to change. 

The length of the acute period until the height of the dis- 
ease may be very materially prolonged, even though the proc- 
ess does not extend beyond the pars anterior. 

This prolongation may result from the longer course of the 
entire acute stage, so that three or even four weeks may 
elapse before the disease reaches its height. It then looks as 
if the inflammation spreads more slowly over the entire 
mucous membrane. 

Or the process reaches its acme at the usual time (about 
the middle of the third week or even earlier), but remains there 
for a week or more, instead of a few clays. 

The course of the disease is much more often prolonged by 
disturbances during the last stage. In typical cases the 
disease diminishes uniformly in intensity and extent, after 
the acme, in about three weeks. In many cases, however, this 
improvement is not uniform but interrupted. The disease im- 
proves, then remains at a standstill for a time, again improves, 
and so on. 

In equally numerous cases recovery is interrupted by re- 
lapses. The process has passed its acme and made a step 
towards recovery, when suddenly a relapse sets in. The acute- 
ness of the process, the secretion and subjective symptoms 
increase, and a second acme is reached, usually less pronounced 
than the first. Thus several relapses, whose intensity usu- 
ally grows less with each succeeding one, interrupt the course 
of the disease until finally recovery is established. These re- 
lapses may even occur during the terminal mucous stage of 
clap. 

The causes of this abnormal course are partly external, 
partly in the patient. It may result from constitutional 
anomalies. Scrofula, cachectic frame, poor nutrition, and 
syphilis delay the course of clap even without external noxa, 
and are at the bottom of numerous relapses. But pollutions 
are the most frequent cause of a protracted course. The 
physician then finds himself confronted by a vicious circle, 
which is not always easily broken. The acute process causes 



BlenorrJicea of the Sexual Organs. 61 

erections and pollutions; these increase the acuteness of the 
inflammation and thus prove a renewed cause of increased sex- 
ual irritation. If the pollutions are numerous in the acute 
stage they intensify the inflammation; if the}^ occur at the 
acme they prolong* the latter, and in the terminal stag*e they 
are the cause of frequent relapses. 

External causes may prolong* the disease in a similar way. 
Coitus acts in an analogous manner to pollutions, as do ex- 
cesses in Baccho, ingestion of spicy food, exhausting exercise, 
walking, riding, driving and dancing. 

Intercurrent diseases also affect the course of blenorrhcea. 
In acute diseases all the symptoms cease so long as the fever 
continues. It seems to be cured, but returns after the cessa- 
tion of the fever. Acute general diseases, which cause great 
prostration of the body, favor a protracted course of clap, and 
certain affections, particularly typhoid fever, are apt to cause 
very acute inflammation or even gangrene in urethritis (Hoel- 
der, 1851). Colds, digestive disturbances, particularly intesti- 
nal catarrh, aggravate the course of clap. Finally we may 
mention that in severe jaundice the pus of gonorrhoea not in- 
frequently possesses a deep, saffron -yellow color, which disap- 
pears with the removal of the jaundice. 

Varieties. — We have already said that the severity and 
duration of the disease are subject to material variations. It 
is well to distinguish three large groups, which merge injbo one 
another. 

1. Subacute Form. — The first infections rarely, repeated 
infections more often, assume a subacute torpid course from 
the start. The incubation and prodromal stages last longer, 
the intensity of the inflammatory stage is less, the pain, sex- 
ual irritative phenomena and general symptoms are almost 
or entirely absent. The secretion long remains serous, opal- 
escent, gelatinous, although its amount may have increased. 
It never becomes more than muco-purulent, although pus can 
always be demonstrated microscopically and macroscopically 
at some stage, and I doubt the existence of a purely mucous 
catarrh after blenorrhagic infection. Gonococci can always 
be found quite abundantly in the secretion; in the beginning 
the flat and transition epithelium cells persist very long and 
always contain gonococci. The number of pus cells is rela- 
tivelv small. The impression is created in these cases as if 



62 Blenorrhoea of the Sexual Organs. 

either the virus is weak or the receptivity of the soil is dimin- 
ished arid the gonococci have penetrated less deeply, so that 
epithelial desquamation suffices for their removal, and irrita- 
tion of the papillary body with secondary emigration of pus 
cells occurs only to a slight extent. This form is as insidious 
as it is mild in its manifestations. The subjective symptoms 
are so slight that they are often entirely overlooked by the 
patient. Noxious influences may give rise to exacerbations, 
but these are often only temporary. And so the process 
spreads not infrequently to the pars posterior, and there gives 
rise to the development of subacute and chronic urethritis 
posterior and prostatitis. 

2. Acute Form. — Purulent clap, the type of the acute ure- 
thritis as described by us, and is especially observed at the 
first infection. 

3. Peracute Form, or phlegmonous clap, with intensifica- 
tion of all the objective and subjective symptoms. Incuba- 
tion and the prodromal stage are short, the symptoms of the 
acute stage intense. Marked swelling of %he entire penis with 
oedema of the prepuce, lymphangioitis, abundant purulent 
secretion, associated in rare cases with the exfoliation of 
croup-like membranes, or a reddish brown to black color of 
the pus on account of admixture with blood, marked symp- 
toms of sexual irritation, chordee and pollutions, intense pains, 
pronounced implication of the general system; the number 
of gonococci in the secretion is often enormous. 

Posterior Acute Urethritis. 

In discussing the course of acute anterior urethritis we 
have mentioned that the inflammatory stage increases up to 
a certain point, and then slowly diminishes to complete recov- 
ery. The amount of secretion in the urine varies in a corre- 
sponding manner. If the test of the two vessels is made, the 
first urine passed alone is cloudy, the second is clear, and there 
is always a correspondence between the amount of pus escap- 
ing from the meatus and the cloudiness of the urine. The 
reason is evident. The pus produced in the pars anterior can 
only cloud the first urine, and not being retained by any mus- 
cular force, it must flow towards the orifice of the usually 
pendulous urethra. 

In the third week occurs the turning point in the course of 



Blenorrhcea of the Sexual Organs. 63 

urethritis, the acme which, whether longer or shorter in dura- 
tion, always forms a boundary stone, which is indicative of a 
change. We are already acquainted with the change for the 
better, but a change for the worse may also occur. The blen- 
orrhagic process, hitherto confined to the pars anterior, passes 
the compressor urethra? and extends to the pars posterior. 
The blenorrhoea thus attacks the entire urethral mucous 
membrane to the ostium urethra? vesicale. 

With this transition the blenorrhagic process has become 
a much more severe disease. The typical course has not ceased 
altogether, but it is rarer. Disturbances of the typical course 
by complications and spread of the blenorrhagic process are 
more common, the prognosis more serious, the treatment is 
more difficult. 

The spread of the disease to the pars posterior occurs at a 
time when the acuteness of the process in the pars anterior is 
diminishing and does not interfere with the latter. On the 
contrary, I am inclined to maintain that the development of 
posterior urethritis favors the rapid termination of anterior 
urethritis. Disease of the pars posterior spreads quite rapidly 
over the entire mucous membrane, and rapidly attains its 
maximum, but recovery then occurs very slowly, after a usu- 
ally long protracted subacute stage. In other cases acute 
symptoms are absent and the course is subacute and pro- 
tracted from the beginning. 

The direct anatomical connection of the short pars poste- 
rior with a number of other organs, the prostate, bladder, 
seminal vesicles, epididymes, offers the most favorable condi- 
tion for the spread of the inflammatory process, and urethritis 
posterior is often merely a temporary forerunner of cystitis, 
prostatis, vesiculitis, epididymitis. 

Whenever these complications occur, posterior urethritis is 
always present. The latter is the agent in the production of 
these processes, but they may develop together, i.e., posterior 
urethritis and prostatitis, cystitis and epididymitis may appear 
almost at the same time. Or the development of posterior 
urethritis may precede these complications for a long time. 
Thus, the former may almost have run its course, then relapse 
on account of external noxious influences, and the first or even 
a subsequent relapse may give rise to the development of the 
complications mentioned. 



64 BlenorrJicea of the Sexual Organs. 

I have already said that posterior urethritis occurs after 
the acme of anterior urethritis. It does not develop, there- 
fore, before the beginning- of the third week after infection, 
except under special circumstances, as, for example, examina- 
tion of the diseased urethra with the sound and direct trans- 
port of blenorrhagic pus to the posterior portions of the ure- 
thra at an earlier period. 

As a matter of course it may develop at a later period. It 
does not develop necessarily after the first acme, but may 
follow a relapse of the anterior urethritis. 

After an examination of fifty cases Heisler (1891) states 
that posterior urethritis occurs 

In the 1st week after infection in 20 per cent. 



Si 


it 


2d 


ti 


a 


it 


" 34 


a 


a 


3d 


a 


tt 


tt 


« 14 


St 


a 


4th 


a 


it 


a 


" 20 



Despite careful observation I have never observed such an 
early development in cases which were not treated locally. 

Rona (1891) occupies an exceptional standpoint. He main- 
tains that every urethritis which has extended to the bulb 
also passes into the pars posterior. According* to him an- 
terior urethritis affects only the pendulous portion, while 
posterior urethritis involves the bulb, membranous and pros- 
tatic portions. 

The causes of the development of posterior urethritis are 
internal and external. 

Internal causes are to be looked for in the constitution of 
the patient. In cachectic individuals, those suffering from 
chronic diseases, such as tuberculosis, scrofula and syphilis,, 
anterior urethritis is generally followed spontaneously by 
posterior urethritis, usually about the third week. Even 
without a decided cachexia the urethra of some individuals- 
forms a favorable soil for the virus, and it is particularly 
blonde,- slender individuals, with a tendency to catarrh in 
general, who also have a tendency to the development of pos- 
terior urethritis. It is also certain that a patient who has 
once suffered from posterior urethritis, will again be attacked 
by it during the course of another infection. 

In all these cases the extension of the disease occurs 



Blenorrhasa of the Sexual Organs. 65 

immediately after the first acme, i.e., in the third week, and 
usually without any noticeable subjective symptoms. 

All the external causes which give rise to an exacerbation 
or relapse of anterior urethritis, excesses in venere and Baccho, 
spicy food, alcoholics, pollutions, excessive exertion, may also 
cause the spread of the process to the pars posterior. This is 
also true of premature or unskilful injections with strong or 
non-antiseptic fluids, or of instrumental interference during 
the course of anterior urethritis. Under such circumstances 
the latter usually develops brusquely, with notable subjective 
symptoms. 

If the anterior urethritis had been reduced to slight symp- 
toms at the time of the action of the irritant, exacerbation of 
the former usually remains absent in case posterior urethritis 
develops. 

The relative frequency of anterior and posterior urethritis 
cannot be accurately determined. Leprevost (1884) claims to 
have observed posterior urethritis in |-th, Eraud (1886) in fths 
of all cases. Jadassohn (1889) has observed it in 87.7 per 
cent, of his cases of urethritis which had lasted four to six 
weeks. According to Letzel, it occurs in 92.5 percent, of cases 
which have lasted seven to ten weeks. In cases of urethritis 
lasting eight to ten weeks Rona (1891) found posterior ure- 
thritis in sixty- two per cent, and in sixty-six per cent, of cases 
which lasted longer. 

These differences of opinion depend in part upon the 
method of examination. It is evident that the test of the 
two beakers will show a smaller proportion of cases than the 
more exact irrigation test, which is carried out in the follow- 
ing manner. Several hours after the last micturition the pars 
anterior is washed out with sterilized water by means of a 
catheter introduced as far as the bulb, and the urine which is 
passed immediately afterwards is then examined. If not 
properly performed, however, this test may apparently 
demonstrate a posterior urethritis which does not exist. The 
irrigation may not wash out all the pus from the pars anterior, 
or the catheter may carry secretion into the membranous 
urethra. This pus will then appear in the urine and will be 
regarded as the secretion of the pars posterior. 

The proportion of posterior to anterior urethritis will also 
vary according to the clinical material. Thus the former is 
5 



66 Blenorrhcea of the Sexual Organs. 

comparatively rare in hospital patients, who remain in bed 
under strict supervision during- the course of an acute ure- 
thritis. It is more frequent among the better class of private 
patients, but most frequent among dispensary patients. 
There were sixty-three per cent, among my private patients, 
eighty- two per cent, among my dispensary cases. 

If the extension of the process to the pars posterior occurs 
without s3 T mptoms, the anterior urethritis appears to run its 
normal course and to approach recovery. But one Symptom 
will not escape us if the patient is examined with any degree 
of care. On examining the urine it will be found that the 
cloudiness is considerable when compared with the diminish- 
ing suppuration visible at the orifice of the urethra. This cir- 
cumstance alone is an indication that, in addition to the small 
amount of pus produced in the pendulous portion, and which 
can cause only slight cloudiness of the urine, the cloudiness 
must be due to some other cause. 

If we now make the test of the two beakers, i.e., direct the 
patient to pass the urine in two portions, not alone will the 
urine in the first giass be found very cloudy, but also that in 
the second glass, though to a much less extent. 

The latter can result only from cloudiness of the urine in 
the bladder. All the pus which remains in the urethra is 
washed away by the first stream of urine, and if the urine in 
the bladder itself is clear, that passed into the second vessel 
must also be clear. 

The pus of anterior urethritis can freely escape externally, 
but its entrance into the bladder is prevented by the firm 
closure of the compressor. What becomes of the pus pro- 
duced in the pars posterior ? 

The tonus of the pars membranacea and prostatica nor- 
mally closes these parts in such a way that no lumen, or only 
a capillary one, is present. This tonus is still further in- 
creased by the inflammatory irritation, and the accumulation 
of large amounts of pus is therefore impossible. 

The pus of the pars membranacea will endeavor to escape 
from the tube which compresses it on all sides, and will there- 
fore flow forwards into the bulb, backwards into the pars 
prostatica. 

The pus of the prostatic portion will endeavor to escape in 
the same way. Its escape anteriorly is prevented by the 



Blcnorrhcea of the Sexual Organs. 6j 

tonic contraction of the pars membranacea. There is no ob- 
struction posteriorly, because the bladder is not closed against 
the urethra and possesses no power to prevent the entrance 
of solid or fluid bodies from the prostatic portion. The pus of 
the pars prostatica will therefore enter the bladder and caus** 
cloudiness of the urine accumulated there. Another circum- 
stance must be taken into consideration. So long- as the blad- 
der is moderately filled the pars prostatica remains closed. 
But when the bladder becomes fuller the pars prostatica is 
used for the reception of the urine. It is therefore evident 
that the pus produced in the pars prostatica and in part de- 
posited in it will be mingled with the urine in the bladder. 
The cloudiness of the urine will therefore be most marked 
when prolonged retention of urine permits the formation of 
larger amounts of pus. On the other hand the pus will only 
enter the urine when its amount is so large that it no longer 
finds room in the pars prostatica. When micturition is fre- 
quent, and when only small amounts of pus are produced which 
could not enter the bladder, the urine accumulated in the blad- 
der will remain clear. Hence the same individual will pass a 
clear second urine if micturition is frequent, and a cloudy second 
urine if micturition is infrequent. These frequent changes 
from a clear second to a cloudy second urine are one of the 
most important characteristics of acute posterior urethritis, 
and an important differential sign between urethritis and cys- 
titis, hi which the mucus and pus which cloud the urine are 
produced in the bladder itself, and therefore a second clear 
urine is impossible. 

If the posterior urethritis is very acute, the second urine 
is always cloudy; if it is subacute and the quantity of pus 
smaller, the urine will only be cloudy after prolonged retention. 

Posterior urethritis also presents a tendency to nocturnal 
exacerbations. The prolonged retention of urine at night thus 
coincides with the greater production of pus, and individuals 
who, during the remission of the inflammation in the day time 
(when they also urinate more frequently) pass a clear second 
urine will present a distinct cloudiness of the second urine 
passed in the morning. Hence follows the important rule 
that posterior urethritis cannot be excluded unless the second 
portion of the first urine passed in the morning is clear. 

The test of the two vessels, especially with the morning 



68 Blenorrhcea of the Sexual Organs, 

urine, will permit us to make a diagnosis even in cases of slow 
posterior urethritis, which beg-in without any symptoms. 

In these cases the first portion of urine is always more 
cloudy than the second. The urine has been made cloudy in 
the bladder, but the first portion, in its passage through the 
urethra, carries with it all the pus found there. The second 
portion passes through the urethra after it has been cleansed 
of pus, and is therefore not rendered still more cloudy. 

The degree of cloudiness of the second urine, since it depends 
upon the excess of pus produced in the pars posterior, is a 
gauge of the intensity of the inflammation. 

In some cases posterior urethritis develops brusquely, and 
is characterized by a series of often very typical symptoms. 

Among these the vesical tenesmus is the most striking, 
and the most annoying to the patient, and its severity is pro- 
portionate to the degree of inflammation. In the most acute 
cases the tenesmus is constant and extremely distressing. It 
forces the patient to urinate every five to ten minutes. The 
amount of urine discharged is then very small, since too little 
time is given for the filling of the bladder. The micturition 
does not relieve the tenesmus, which continues whether the 
bladder is full or empty. It is entirely independent of the 
urine and is not produced by the irritation of the latter. In 
discussing the physiology of the subject, we stated that the 
normal desire to urinate is called forth by the stimulus exer- 
cised by the urine upon the pars prostatica. But this feeling 
can also be provoked by other means — for example, by the in- 
troduction of a bougie or catheter. This is also the case when 
violent inflammation irritates the pars prostatica. 

The irritation of the inflamed mucous membrane of the pars 
prostatica then causes permanent desire to urinate, and hence 
its complete independence of the condition of fullness of the 
bladder. Every influence which intensifies the inflammation 
also increases the vesical tenesmus. It is therefore increased 
by rapid movement, especially driving and riding, and dimin- 
ished by quiet. 

The vesical tenesmus is more characteristic in subacute 
than in acute cases. If the patient has evacuated the bladder 
he feels no tenesmus so long as the organ is gradually filling. 
But after retention of urine for a few hours the desire to uri- 
nate, which can usually be overcome without difficulty by 



BlenorrJioea of the Sexual Organs, 69 

healthy individuals, becomes at once so imperative that the 
patient cannot restrain it, at the danger of involuntary mic- 
turition. The physiological desire to urinate is caused by the 
stimulus of the first drops of urine which, when the bladder is 
full, pass into the posterior portion of the pars prostatica. 
The desire is slight at first, and increases with the amount of 
urine entering the pars prostatica and the increasing pressure 
to which it is subjected. 

If the mucous membrane of the pars prostatica is moder- 
ately inflamed, the stimulus of the inflammation will not pro- 
duce spontaneous desire to urinate. But the first drops of 
urine which reach the inflamed mucous membrane will produce, 
instead of the physiological, an intense desire whose severity 
varies according to the degree of inflammation. 

The more acute cases of posterior urethritis are usually 
accompanied by haematuria. In the milder cases of haema- 
turia a few drops of blood only appear on pressing out the last 
drops of urine. This blood is squeezed out of the inflamed, 
perhaps eroded mucous membrane of the pars prostatica by 
the contractions of the sphincters of the bladder; it does not 
come from the bladder but from the pars posterior. This was 
proven by Horovitz (1885). When the last drops of urine were 
passed, in patients suffering from haematuria, he introduced 
an elastic catheter into the bladder, washed out the organ, 
and allowed the instrument to remain. The urine discharged 
from the bladder through this catheter was found to be free 
from blood, a clear proof that the hemorrhage is not situated 
in the bladder itself. When the hemorrhage is more severe the 
blood which flows from the pars posterior, enters the bladder 
wuth the pus and gives the urine a bloody color. The patient 
then passes urine which is bloody in both portions, and a few 
drops of blood are voided with the last drops of urine. As a 
matter of course violent tenesmus is always associated with 
this acute stage. 

The views here expressed concerning posterior urethritis 
are generally accepted, but some dissenting voices have been 
raised. 

Fuerbringer (1890) is not convinced by the arguments ad- 
duced in favor of the regurgitation of pus from the pars pos- 
terior into the bladder, and assumes a cystitis whenever cloud- 
iness of the second portion of the urine, tenesmus, and terminal 
haematuria are observed. 



JO Blenorrhcea of the Sexual Organs. 

A very different view is held by M. v. Zeissl (1888). He 
denies the possibility of the regurgitation of pus from the pars 
posterior into the bladder, and maintains that the second por- 
tion of urine is clear in every prostatic urethritis, and that its 
cloudiness always indicates cystitis. On the other hand, he 
acknowledges that tenesmus and terminal hematuria are ob- 
served in prostatic urethritis without affection of the bladder. 
Hence it follows that there must be cases in which tenesmus 
and terminal haematuria are present but the second portion of 
the urine is clear. Such cases have not been described by any 
observer. The simple fact is that cloudiness of the second por- 
tion of the urine, with or without tenesmus, is often observed 
during the course of blenorrhcea. The question then arises, is 
cystitis present in all these cases, as Fuerbringer assumes, or 
does mere disease of the pars posterior, without implication of 
the bladder, suffice to produce these symptoms, as we have 
good reason to believe ? 

Subjective Symptoms. — Other subjective symptoms are 
almost always noticeable. The patients usually complain of 
burning, tickling, perhaps of slight lancinating pains in the 
deep portions of the urethra and towards the anus, which 
often increase after micturition and defecation. 

Sexual Irritative Symptoms. — These vary according to 
the intensity of the process, and are analogous to those ob- 
served in acute anterior urethritis. Priapistic, painful erec- 
tions are generally absent. The erections are painless but, 
on the other hand, pollutions are frequent and the moment 
of ejaculation is accompanied by a sticking pain in the deep 
portions of the urethra. The pollutions which are especially 
frequent in subacute posterior urethritis, and often occur 
several times a week, owe their development to the inflamma- 
tory irritation of the caput gallinaginis and are so character- 
istic that if a patient begins to complain of frequent pollutions 
in the third or fourth week of an urethritis, the physician 
should always examine concerning the existence of a posterior 
urethritis. 

Secretion. — The secretion is analogous to that of anterior 
urethritis, i.e., muco-purulent, the proportions varying ac- 
cording to the acuteness of the inflammation. The more 
acute inflammations always produce more pus. The turbid 
urine in the two beakers will therefore deposit the same two 



Blenorrhoea of the Sexual Organs. 71 

layers, an upper mucous and a lower purulent layer, in vary- 
ing- proportions. Examination of the pus corpuscles of the 
urine in the second glass with alkaline methyl blue almost 
always shows a greater or smaller number of characteristic 
gonococci heaps. 

In rarer cases the sediment of the second portion, or the 
secretion after washing out the pars anterior, does not contain 
gonococci. In such cases there is merely a mild affection of 
the pars posterior. While the secretion of the pars anterior is 
abundant and purulent, the second urine shows only slight 
cloudiness or only a few shreds are found in the urine after 
washing out the pars anterior. Jadassohn (1892) believes 
that in these cases the posterior urethritis is due to the carry- 
ing of toxines of the gonococci into the pars posterior through 
the medium of the circulation. 

On the other hand posterior urethritis is associated with 
a symptom peculiar to it, viz., a not inconsiderable albumin- 
uria. An amount of albumin is found in the filtered urine on 
boiling and on the addition of nitric acid, which is out of pro- 
portion to the pus. This albuminuria is intimately connected 
with the vesical tenesmus, increases and diminishes with the 
latter, and reappears on the reappearance of the tenesmus. 
The origin of this symptom is not fully explained. It is 
conceivable that, among the many reflex symptoms produced 
by acute inflammation of the pars prostatica, albuminuria 
also constitutes a reflex, vaso-motor disturbance. Ultzmann 
(1880) accepts Runeberg's theory. According to the latter 
writer albumin will filter from the glomeruli into the renal 
tubules of the healthy kidney, either when the arterial pressure 
in the glomeruli diminishes or the pressure in the tubules ex- 
ceeds the secretory pressure, as happens in damming back of 
the urine in the ureter. Now the acute inflammation of the 
pars posterior and the violent tenesmus which it produces, 
give rise to reflex muscular spasms. Detrusor spasm also 
appears to occur and increases the tenesmus. Inasmuch as 
the ureters run transversely through the muscular fibres of 
the detrusor vesicas, spasmodic contraction of the latter will 
compress the lowermost part of the ureters, give rise to dam- 
ming back of the urine and thus to albuminuria. The latter 
w r ill cease as soon as the reflex detrusor spasm subsides wdth 
the cessation of the tenesmus, and will return with the recur- 
rence of the spasm. 



*]2 Blenorrhcea of the Sexual Organs. 

As a matter of fact, this albuminuria may be relieved by 
the administration of narcotics. I have repeatedly made this 
observation, which is denied by Fuerbringer, and regard the 
presence of a large amount of albumin in posterior urethritis 
as an evidence of severe irritation. Hence, albuminuria al- 
ways constitutes a warning not to begin with local treatment. 
Balzer and Souplet (1892) have recently studied albuminuria 
in blenorrhcea. Among 424 patients 99 suffered from albumi- 
nuria out of proportion to the amount of pus in the urine. 
Among these 99 patients, 62 suffered from epididymitis, 11 
from epididymitis and cystitis, 5 from cystitis, 21 from uncom- 
plicated blenorrhcea. In the 78 complicated cases there was 
no doubt of the presence of posterior urethritis. Unfortu- 
nately the authors do not mention whether the 21 cases of un- 
complicated blenorrhcea were localized in the pars anterior or 
also involved the pars posterior. 

General Symptoms. — These are similar to those of anterior 
urethritis, but are usually more intense. The acute form with 
its distressing tenesmus is accompanied by the most severe 
general symptoms. The tenesmus, although constant, is 
subject to spasmodic exacerbations whose intensity often 
causes the patients to cry out aloud and brings beads of per- 
spiration to their brows. The general condition then is usually 
very much depressed, the sallow complexion and the rings 
around the eyes convey the impression of a serious disease. 
Fever is generally present. The appetite is usually lost, and 
there is often obstinate constipation. 

In the subacute cases the general organism is not notice- 
ably affected. 

Forms. — According to the intensity of the process we dis- 
tinguish three typical forms of the disease. 

1. Subacute Form. — A predominantly catarrhal disease 
with production of an almost exclusively mucous secretion, 
which contains few pus cells. In many of these cases the 
second portion of the urine is only cloudy in the morning, but 
clear during the day. The subjective symptoms are confined 
to somewhat" imperative, perhaps more frequent, desire to 
-urinate. 

2. Acute Form. — The secretion more purulent, its amount 
greater, so that the second portion of urine is almost always 
cloudy and is only clear occasionally during the afternoon, 



Blenorrhoea of the Sexual Organs. 73 

when the remission of the inflammatory process coincides with 
the more frequent micturition resulting- from the meal. Sub- 
jective symptoms are more severe, especially more frequent 
and imperative tenesmus. 

3. Peracute Form. — The secretion abundant and purulent, 
the second urine always very cloudy, tenesmus very violent, 
hsematuria after micturition, subjective symptoms marked, 
general condition very much affected. 

Course. — We have already said that acute posterior 
urethritis usually reaches its acme rapidly, and then takes a 
slow course before complete recovery. The stage of greatest 
intensity may become ominous from the fact that the inflam- 
matory process may extend beyond the urethra to adjacent 
structures, the prostate, bladder, epididymes, and produce in- 
flammation of these organs. 

The slow course of the stage of recovery may be delayed 
still further by the fact that external injurious influences may 
induce relapses, and these may be followed by complications. 

In like manner the frequent pollutions provoked by the 
process itself may cause notable prolongation of the acme of 
the inflammation, increase of the inflammatory symptoms 
and relapses. 

With the long duration of the acute stage and the frequent 
relapses, recovery is made difficult and the development of 
chronic changes is favored. 



Diagnosis and Differential Diagnosis. 

If we have a patient suffering from a mucous, muco-puru- 
lent or purulent discharge from the urethra, two questions 
must be answered : 1. Is this discharge gonorrhceal ? and 2. 
How far along the urethra does the gonorrhceal disease 
extend, particularly with regard to the compressor urethras ? 

The first question is answered by the results of microscopi- 
cal examination, and depends directly on the demonstration 
of gonococci in the pus or muco-pus. This question is so im- 
portant, and attended with so much responsibility to the 
physician, that it necessitates careful examination. A single 
examination is often insufficient. 

The number of gonococci in the purulent and muco-puru- 
lent secretion of florid blenorrhagic urethritis is usually con- 



74 Blenorrhoea of the Sexual Organs. 

siderable. If we have examined several, at least two to four, 
cover-glass preparations from an acute suppuration of the 
urethra and have not found gonococci, the negative results 
exclude blenorrhoea. 

This is not true of the mucous secretions of the initial and 
terminal stages. In these the number of gonococci is small, 
particularly in the terminal stage. Accordingly, if we find 
no gonococci in several preparations, we should not exclude 
blenorrhoea, but should repeat the examinations later and also 
take the course of the disease into consideration. If the 
mucous secretion has only lasted a short time, it will soon be 
converted into a purulent secretion, in which the demonstra- 
tion of gonococci is not difficult, and clears up the diagnosis. 
If we have to deal with the terminal stage, this must have 
been preceded by a purulent discharge, as will appear from 
the patient's statements. The process will then either subside 
spontaneously in a little while and thus make the question of 
its character unnecessary, or a relapse will occur with purulent 
secretion, in which the demonstration of gonococci is generally 
easy. 

But in every case in which the diagnosis of blenorrhoea is 
made, the micro-organisms found by us must be fully proven 
to be gonococci, and must possess a series of characteristics. 
The absence of even one of these makes the diagnosis doubtful. 
These characteristics are : 

a. Shape. — We have already described gonococci, and will 
here merely call attention to their shape, which resembles that 
of coffee beans, and to the fact that, inasmuch as they are dip- 
lococci, they are always found joined in twos and twos, with 
their flat or slightly concave surfaces directed towards one 
another. 

b. Grouping. — The mode of their division gives rise to the 
circumstance that the gonococci are never found in chains, 
however short, but always in heaps. Within these groups 
we usually find two cocci pairs closer to one another in sarcina 
shape. The number of single cocci (not in pairs) is always 
divisible by two, but usually also by four. 

c. Staining. — Gonococci are readily stained by aniline col- 
ors, but they also lose their staining readily in comparison with 
the majority of other cocci. They are decolorized by treat- 
ment with alcohol, according to Gram's method, while this 



Blenorrhcea of the Sexual Organs. 7$ 

does not affect the staining- of most other cocci. In order to 
demonstrate this, a cover-glass preparation is stained with 
gentian violet aniline-water, placed for one minute in potas- 
sium iodide solution, washed, decolorized in alcohol, and then 
stained with a watery solution of fuchsin. The gonococci 
then appear red, while other cocci and bacteria have a deep 
blackish-blue color. 

d. Position. — The heaps of cocci must always be found in 
the protoplasm of pus cells. This is proven by the fact that 
the cocci and the contour of the cell nucleus are equally dis- 
tinct at the same focus, and that the cocci do not project 
bej^ond the edge of the protoplasm. The number of gonococci 
in one cell varies from one or two pairs to complete distention 
of the entire cell body, which often appears dilated. Very 
characteristic of cocci, also, is the finding of nuclei of pus cells, 
enclosed in heaps of gonococci, and which no longer present a 
cell contour. The cocci pairs are then usually aggregated 
more closely towards the centre, more loosely towards the 
periphery of the mass. These masses are derived from the 
destruction of pus cells which have been filled with cocci. 

e. Number. — If a purulent secretion is really blenorrhagic 
the number of gonococci heaps is always considerable, and 
the discovery of a few diplococci, even if situated in cells, is 
not convincing. 

Lustgarten and Mannaberg (1887) have recently attacked 
the diagnostic significance of gonococci, in view of the discovery 
of diplococci also enclosed in cells, in the normal urethral mu- 
cous membrane. So far as concerns acute urethritis I must op- 
pose their views (I will discuss at a later period the significance 
of gonococci in the diagnosis of chronic urethritis). For many 
years I have had the opportunity of examining, with regard 
to micro-organisms in the pus, every case of acute and chronic 
urethritis (and their number is not small) which came under my 
observation. There is no doubt that, in addition to gonococci, 
other micro-organisms are also found in blenorrhagic pus, but 
these never give rise to even the slightest diagnostic doubt. The 
number of foreign micro-organisms, especially cocci, is so slight, 
and they are found to such a large extent outside of cells (with 
few exceptions), and their shape and grouping are so different 
from those of gonococci, that the differences in staining (which 
were not tested by Lustgarten and Mannaberg) are unnecessary 



j6 Blenorrhoea of the Sexual Organs. 

to make a positive differential diagnosis. The impression is 
never created that these cocci are due to more than accidental 
soiling', or that they increase in the pus. In fact the vital 
conditions in the normal and blenorrhagic urethra are so 
different that, without strict proof, we can hardly arrive at 
the conclusion that the micro-organisms of the normal urethra 
can be propagated in the blenorrhagic canal. 

Steinschn eider and Galewsky (1889) have found four vari- 
eties of diplococci in the normal urethra and the secretion of 
blenorrhoea. They are distinguished from gonococci by means 
of Gramm's method and also by the facility with which they 
may be cultivated. Petit and Wassermann (1891) found in 
the normal urethra five kinds of cocci, six kinds of bacilli, two 
sarcinse, two yeast spores, none of which proved pathogenic. 
They were unable to find the pseudogonococci of Lustgarten 
and Mannaberg. 

The direct proof that a urethral suppuration is blenor- 
rhagic must be adduced, for the reason that there is also a 
series of other catarrhal affections of the urethra which 
present similar symptoms. 

Thus, chemical and mechanical irritants, which act upon 
the urethra, produce symptoms which apparently are entirely 
like those of clap. These suppurations can be distinguished 
from those of blenorrhoea by two factors. In the first place, 
incubation is wanting, the reaction follows the irritant in- 
fluence at once, rapidly increases to its acme, and soon disap- 
pears. The suppuration is confined to the part of the mucous 
membrane which has been injured by the irritant, and presents 
no tendency to migration and peripheral spread, and no ten- 
dency to a protracted and chronic course. 

Any one who has the opportunity of making injections of 
concentrated astringents into the urethra, may convince him- 
self of this fact. 

If a patient, suffering from chronic urethritis, receives an 
urethral injection of a two to ten per cent, solution of nitrate 
of silver, violent reaction occcurs at once, attended with 
violent, burning pain. Three or four hours after the injection, 
thick, creamy pus, like that of acute urethritis, is discharged, 
and the urine is very cloudy, but the entire reaction rapidly 
diminishes within twenty -four hours. The same observation 
may be made in those cases in which, usually by accident, 
caustic injections have been made into the healthy urethra. 



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BlenorrJioea of the Sexual Organs. J J 

The adherents of the theory which denies the existence of 
a blenorrhagic virus also deny the difference between clap 
and traumatic and chemical catarrhs, as regards incubation 
and course, and they oppose a thousand-fold experience with 
the single experiment made by Swediaur (1798). 

This writer injected a solution of ammonia into his own 
urethra, and suffered in consequence from an urethritis which 
developed without incubation, extended in three exacerbations 
as far as the neck of the bladder, and lasted seven weeks. 
Entirely apart from the fact that this experiment confirms 
the difference, so far as regards incubation, between virulent 
and non-virulent Menorrhagia, it is time to control this ex- 
periment, which is a century old and performed under one 
knows not what conditions, by others made with proper pre- 
cautions, or to allow it to rest, like Hunter's experiment, and 
to regard it as a mere historical curiosity. 

Urethral catarrhs, usually of a mucous character, can also 
be produced by other irritants. 

Thus, slight mucous or muco-purulent catarrhs, which 
rapidly heal spontaneously, develop after coitus with men- 
struating or leucorrhceic women. Microscopical examination 
of the secretion usually shows several diplococci and rod 
varieties, one of which (Plate IV., Fig. 10), in view of the con- 
stancy of its occurrence in several cases, and its notable pre- 
dominance over other rods and cocci, perhaps stands in a 
close causal relation to the affection. Gonococci were absent 
in these cases, despite the tolerably abundant suppuration 
and the careful examination of numerous preparations. 

But purulent urethral catarrhs with a mild course also ap- 
pear to be produced by other pathogenic micro-organisms than 
gonococci. Aubert (1884) reports three cases of urethritis, in 
which he found one and the same form of coccus; one case was 
followed by epididymitis and cystitis. Bockhart (1886) reports 
afteen cases of infection — among these were ten married 
men — produced by vaginal secretion, which was followed by 
mild muco-purulent catarrh; in two cases alone did it extend 
to the pars posterior and epididymis. As the cause, Bockhart 
found extremely small cocci, analogous to gonococci; he made 
pure cultures and performed two inoculations with positive 
results. In two other cases evident streptococci were found. 

Mild muco-purulent catarrhs of the urethra with slight se- 



yS Blenorrhcca of the Sexual Organs, 

cretion, which are manifested merely by agglutination of the 
meatus and a few flakes in the urine, may occur as symptoms 
of syphilis. Lee, Vidal and Hammond discuss this affection, 
hut the most detailed description was furnished by Tarnowsky 
(1872). They consist in the formation of superficial erythe- 
matous or papular efflorescences on the mucous membrane of 
the urethra, which occur as a part of a general secondary 
syphilis or alone as a relapse of the secondary syphilide. These 
erythematous or papular ulcerations secrete the small amount 
of catarrhal or, though rarely, purulent secretion, which ap- 
pears at the meatus and simulates blenorrhoea. Examination 
of the secretion, the demonstration of recent syphilitic symp- 
toms or their residua, the previous history and the results of 
antisyphilitic treatment prove the diagnosis of syphilitic as 
distinguished from blenorrhagic urethritis. 

Finally, attention must be called to still another affection. 
Diday (1860) first directed special attention to patients who 
complain of obstinate urethritis and constantly express a drop 
of pus from the meatus. If we examine carefully it is found 
that this pus does not come from the meatus, but from small 
openings on the inner surface of the lips of the meatus. In 
this locality are found glands, whose short excretory ducts 
empty on the inner surface of the lips of the urethra. Puru- 
lent catarrh of these glands often occurs independently, per- 
haps also as the result of blenorrhoea, and can only be cured 
by destroying them with hot needles. 

The similarities between soft and hard chancre at the orifice 
and blenorrhoea are so remote, and the differences usually so 
distinct, that it is sufficient to mention them as possible causes 
of error. 

The second question presented refers to the extent of the 
process, i.e., whether we have to deal with an urethritis an- 
terior or posterior. This question is answered in every case by 
the test of the two beakers. A first cloudy urine and a second 
clear urine indicates a simple anterior urethritis; a second 
cloudy urine means posterior urethritis. But even in posterior 
urethritis the second urine may be clear occasionally, and it is 
therefore advisable to make several examinations. The morn- 
ing urine is especially decisive, in the first place because the 
patient has not urinated for the longest time, and then because 
the morning exacerbation coincides with the retention of urine 



Blenorrhcea of the Sexual Organs. 79 

for several hours. I can recommend as very practical and 
easily carried out a method which I have employed for several 
years with good results. The patient is directed to bring- at 
each visit the morning urine divided into two portions, and 
also to retain the urine in the bladder for several hours before 
the visit. If he then passes the urine into two vessels, and this 
plan is carried out from the beginning of the blenorrhagic 
stage, we are always kept accurately informed concerning the 
extent of the process. 

If the second urine is occasional^ 7 or constantly clear, as 
in subacute cases or the terminal stage of acute posterior 
urethritis, the differential diagnosis may be made by means 
of the irrigation test, recommended by Smith (1880) then by 
Aubert, Eraud, Du Castel, and recently by Goldenberg (1888) 
and Jadassohn (1889). After the patient has abstained from 
urinating for several hours, an elastic catheter is introduced 
as far as the bulb and the pars anterior washed with a weak 
solution of borax, by means of an irrigator or hand syringe. 
If the urine passed after irrigation is clear, anterior urethritis 
alone is present; if it contains flocculi and shreds or is slightly 
mucous and cloudy, posterior urethritis is also present. I 
have already spoken of the possible errors of this test. 

Eveiw reader of these lines and every observer will have 
been struck by the great similarity between posterior urethri- 
tis and cystitis. A few distinctions between the two diseases 
have been already noted ; the differential diagnosis will be dis- 
cussed in the consideration of cystitis. 

Prognosis. 

Simple and uncomplicated blenorrhcea, whether situated in 
the pars anterior or posterior, is a harmless affection in the 
large majority of cases. The prognosis as regards duration is 
not so good. Here Ricord's dictum holds true : " Une chaude 
pisse commence, Dieu le sait quand elle finira." 

The causes of its transition into a chronic condition are in- 
numerable, and such an event is connected with so many cir- 
cumstances which are independent of the physician, and in part 
of the patient, that the former should be very reserved in 
making a prognosis. Urethritis with short incubation and 
quite rapid onset has a more favorable prognosis as regards 
rapid termination than the subacute forms, in which the in- 



80 Blenorrhoea of the Sexual Organs. 

cubation lasts longer, and the process slowly reaches a mild 
acme. For this reason, also, the prognosis as to duration is 
more favorable in the first infection than in repeated infections, 
which generally run a subacute course. 

Caution in prognosis is therefore necessary, because the 
process becomes aggravated with its duration, and also be- 
cause of the various sequela? and complications. 

A series of complications may even give rise to symptoms 
which threaten the life of the patient. 

Thus, Post (1887) and Park (1888) have collected a number 
of fatal cases due to phlebitis of the prostatic plexus, pros- 
tatic and periprostatic phlegmons and abscesses, peritonitis 
after inflammation of the seminal vesicles, prostate and epidi- 
dymis, cystitis and pyelonephritis. Among the more remote 
complications gonorrhceal rheumatism, endocarditis, and peri- 
carditis are more apt to terminate fatalty. 

Even a simple uncomplicated blenorrhoea may cause seri- 
ous, dangerous symptoms on account of the intensity of the 
inflammatory phenomena. .We have mentioned a few of these 
fatal cases in describing chordee. 

Apart from this complication an acute urethritis may ter- 
minate fatally when the inflammatory symptoms become very 
acute per se, or as the result of external irritants, or of espe- 
cially unfavorable dietetic and hygienic influences. 

Gervais (1866) mentions three cases in which dangerous 
hemorrhages from the urethra were caused by coitus in the 
acute stage of urethritis. In Paul's case (1875) excesses in the 
diminishing stage of an acute clap were followed by hemor- 
rhage from the pendulous portion. An obstinate stricture 
developed at the point of rupture. 

Even without external influences urethritis may give rise, 
though rarely, to extremely dangerous symptoms. Jeszensky 
(1882) reports the following case: A peasant, set. twenty-three 
years, who had coitus for the last time a week before, was 
admitted on September 8, 1882, to the Rochus Hospital in Pesth, 
suffering from an urethritis of five days' standing. On admis- 
sion the entire penis was found swollen, cold, and the integu- 
ment bluish green. The swollen glans was partly covered by 
the cedematous prepuce; abundant purulent discharge from 
the urethra. Scarification of the integument of the penis was 
performed. The wounds, whose edges rapidly assumed a bluish- 
green color, discharged nasty green pus. Gangrene developed 



Blenorrhcea of the Sexual Organs. 8 1 

in the skin of the prepuce and penis, which exfoliated and 
healed with production of cicatrices. 

The prognosis also depends materially upon the conduct of 
the patient. This furnishes an important reason for caution, 
even in simple cases, and for calling the attention of the patient 
to the possible dangers of an imprudence. 

Anatomy. 

Like the obscure etiological views on blenorrhcea, the no- 
tions concerning its nature and situation were also very ob- 
scure. The imperfect opportunities for making autopsies were 
an important factor in producing this state of affairs. 

The oldest appellation of the disease viz., gonorrhoea (flow 
of semen, from yo^r h seed, and fkw, to flow), showed that the 
ancients identified the secretion of blenorrhcea with semen. 
But this opinion was not accepted universally, and, as we have 
seen, the nature of the secretion as pus was soon recognized 
and the process regarded as inflammatory. From this period 
the disease was regarded as much more serious than it really 
is. There was talk of ulcerations of the urethra. The views 
concerning the nature of the discharge also varied, and these 
uncertainties and essentially different opinions persisted until 
the middle of the eighteenth century. 

Thus, Sydenham (1680) regarded clap as an inflammation 
of the spongy substance of the penis, which gradually passes 
into suppuration. The pus is then deposited in the urethra and 
slowly escapes, as is seen in clap and spermatorrhoea. Zeller 
(1700), Warren (1710), Littre (1711), Astruc (1754) place the 
site of clap in Cowper's glands, the prostate, and seminal vesi- 
cles, and attribute it to suppuration and ulceration of these 
glands. This opinion is explained by the fact that the few 
autopsies made by these writers were performed on individ- 
uals suffering from old, neglected clap, accompanied by strict- 
ures and severe retro-strictural changes and ulcerations. The 
observations made in these cases were then generalized. 

The few writers who, favored by fortune, had the opportu- 
nity of examining recent urethritides post-mortem, soon 
adopted another view. Thus, Laurentius Terraneus (1703) had 
the opportunity of making six autopsies on recent cases, in one 
of which, urethra omnino inflammatione livescebat, glandulse- 



82 BlenorrJicea of the Sexual Organs. 

que disgregatae immodicum extumebant. Terraneus there- 
fore explains blenorrhcea as an inflammation of the entire 
mucous membrane, whose surface produces the discharge. 
Cockburne (1717) expressed the same opinion soon afterwards. 

But the view that there were severe ulcerative changes in 
the urethra still remained the prevailing one. This descended 
to Morgagni, who, in 1745, introduced his divergent views in 
the following words : Etsi pauci forte sint Anatomici a quibus 
tot fuerint, quod a me, urethras viriles dissecatas, et diligenter 
perlustratae; tamen aut rarius quam vulgo existimant, lucu- 
lentiora in eo canali vitia occurrunt quae contagiosam Gonor- 
rhceam comitentur, aut nescio quo casu factum est, ut cum 
magnus hominum hac infectorum sit numerus, ilia ego vitia tarn 
luculenta vix unquam aut ne vix quiclem conspexerim. Mor- 
gagni then passes to the description of his findings, which in- 
cluded merely slight redness, increased moisture of the ure- 
thral mucous membrane, but complete intactness, or at least 
no severe ulcerations, in the urethra, prostate or seminal vesi- 
cles. It is also an interesting observation of Morgagni (which 
was corroborated one hundred years later by Virchow) that 
the pus corpuscles of clap are larger than those found in other 
forms of pus, but Morgagni could not make up his mind to 
call the discharge of clap true pus, and adopted Rondelet's 
term materia puriformis. 

In 1753 Hunter had the opportunity of examining two 
hanged criminals who had been suffering from clap. In neither 
did he find ulcerations of the urethra, but the mucous mem- 
brane, especially within the glans, was very much reddened. 
In subsequent autopsies Hunter found a similar condition of 
the urethra. 

In 1777 Stoll had the opportunity of examining the genitalia 
post-mortem. Greenish pus escaped from the urethra, and the 
meatus appeared reddened. The mucous membrane of the ure- 
thra was swollen for two fingers' breadths from the meatus 
and also in the bulb ; in the place of Morgagni's lacunae were 
found a large number of whitish specks and dots. 

Gendrin (quoted by Gibert, 1836) describes the following 
findings: a soldier, vigorous and robust, suffered, in conse- 
quence of neglect of a blenorrhcea of ten days' standing, from 
retention of urine and fever. The catheter discharged foul- 
smelling urine. Fatal termination after severe general symp- 






Blenorrhcea of the Sexual Organs. 83 

toms. The autopsy showed swelling" of the walls of the bladder 
and several ulcerations in its mucous membrane. The vesical 
peritoneum was inflamed. The entire urethral mucous mem- 
brane had a livid color and was swollen; in the bulb an ulcer 
as large as a 50 centime piece involved the entire circumference 
of the canal, and there were two others, with a diameter of 
about two lines, one in the middle of the pendulous portion, a 
second next to the prostate. 

Lisfranc (1815) states that he made many autopsies on 
individuals suffering from blenorrhcea and who had died of 
adynamic fever. He claimed to have found ulcerations of the 
diseased mucous membrane quite frequently. According to 
Tiis investigations the disease begins in the fossa navicularis, 
extends about the twelfth day to the bulb, and about the twen- 
tieth day to the membranous portion. 

Cullerier secured only one autopsy on a case of acute ure- 
thritis in twenty years, and found two markedly injected 
patches in the region of the fossa navicularis and pars mem- 
branacea, which were connected with one another by stripes 
of inflammatory redness. 

Boyer (1836) found, in one case, merely inflammatory red- 
ness of the pendulous portion. 

Friedberg (1865) describes the following appearances at 
the autopsy of a boy of sixteen years, who had suffered from 
clap for four weeks, and died as the result of an injury to the 
head. The urethra contained quite consistent, greenish-yellow, 
purulent secretion. The mucous membrane was moderately 
swollen in the fossa navicularis and of a dull, dark-red color. 
Much more vivid injection was found in the pendulous portion 
of the urethra and extended about 2" into the pars prostatica. 
The posterior wall of the pars membranacea projected distinct- 
ly and narrowed the lumen of the canal in a striking degree. 
The projection was caused by an extravasation of blood, which 
apparently started from the very vascular cellular tissue sur- 
rounding the mucous membrane, inasmuch as the hemorrhage 
lay not alone between the mucous membrane and the connect- 
ive-tissue envelope, but also between the latter and the cir- 
cular muscular stratum of the urethra. An extensive ulcer 
was situated here on the posterior wall of the mucous mem- 
brane, and its soft, here and there eroded edges ran an irregu- 
lar course and remained at the level of surrounding parts. The 



84 BlenorrJwea of the Sexual Organs. 

ulcer was covered by laudable pus, which could be readily 
washed off. The base of the ulcer showed partly necrotic, 
partly granulating' tissue. In the immediate vicinity of the 
edges it only included the surface of the mucous membrane, 
while it involved the deeper layers toward the centre. A few 
of Littre's glands were distinctly swollen on the left side of the 
upper border of the ulcer. Cowper's gland on the right side 
was swollen to the size of a large pea and contained a yellow, 
tough, consistent, muco-purulent secretion. The opening of 
the gland lay in the ulcer and was occluded by a firm clot ; 
the inner wall of the gland was strongly injected. 

Yoillemier (1868) had the opportunity, in the course of thir- 
teen years, of attending nine autopsies on individuals suffering 
from blenorrhoea, and gave accurate reports. The fifth case 
is the most interesting. A young man, art. twenty-four years, 
died from a railway injury, while suffering from a first attack 
of urethritis of nine days' standing. The urethral mucous 
membrane appeared somewhat contracted. It was swollen 
and reddened over a surface extending 7 cm. from the orifice, 
the openings of Morgagni's lacunae were distinctly visible and 
the mucous membrane thus appeared as if strewn with fine 
openings. In the median line of the canal, 4 cm. from the 
meatus, a lacuna Morgagni was depressed, the surrounding 
parts destitute of epithelium, and as a result a superficial ulcer, 
3 mm. long, 2 mm. broad, had formed. On compression of the 
mucous membrane greenish-yellow pus escaped from the open- 
ings of Morgagni's lacunae. 

A. Guerin (1854) reports the following autopsy : the penis 
was enlarged and oedematous, the swollen prepuce covered the 
glans, and abundant creamy pus could be expressed from the 
urethra. The mucous membrane is moderately reddened, 
Morgagni's follicles distended, and pus could be squeezed out 
of the latter. On section of several follicles they were found 
dilated into sacs, which extended almost 1 cm. into the ure- 
thral walls. The tissue of the bulb is filled with blood, the 
meshes near the mucous membrane contain clots similar to 
those found in veins. The trabecular are soft and yielding. 

Murchison (1875) describes a case in which the patient died 
of blenorrhagic cystitis and nephritis, and the autopsy showed 
redness and swelling of the entire urethral mucous membrane. 

In order to complete the anatomo-pathological history of 



Blenorrhoea of the Sexual Organs. 85 

acute urethritis, we will here describe the endoscopic appear- 
ances. 

Desormeaux (1865) describes acute blenorrhoea as intense 
redness and swelling 1 of the urethral mucous membrane, whose 
surface is uneven and covered with erosions. When the proc- 
ess is about a week old, it extends to the middle of the pars 
pendula. When it becomes older, the anterior parts resume 
the normal appearance while the deeper parts become affected. 

Gruenfeld (1877) described the urethral mucous membrane 
as swollen, ridged, of a dark-red to bluish-red color, the sur- 
face smooth and superficial epithelial losses noticeable here 
and there. The mucous membrane bleeds readily on contact. 

We will now make a resume of the picture of acute ure- 
thritis resulting" from these examinations. 

It constitutes an inflammation of the mucous membrane 
and submucous tissue with all its characteristics, such as red- 
ness and swelling" and secretion of a mucous, muco-purulent or 
purulent discharg-e. The intensity of the inflammation will 
vary, and hence the mucous membrane presents different ap- 
pearances. Sometimes the swelling" will be slig"ht and the in- 
jection dendritic, sometimes the redness and swelling- will be 
very marked. The glands and follicles always appear to be 
affected early and intensely. They become swollen, their 
opening-s g"ape in the shape of a funnel. The inflammation also 
extends to the lumen of the glands, and even the parenchyma 
takes part in the inflammation and the production of morbid 
secretion. If the lumen of the gland or follicle is now occluded 
by a firm plug" of mucus or pus, retention of pus and the for- 
mation of cysts result, as in Guerin's case. Desquamation of 
the epithelium and superficial losses of substance also take 
place at the mouth of the follicle, and if the process is severe 
may lead to small ulcerations (clap ulcers). Deeper ulcers may 
also develop, perhaps, from the rupture of one or more cysts 
due to occlusion of the gland openings. This early and intense 
implication of the glands explains the obstinacy of clap and 
its tendency to relapse. The latter is due to the persistence of 
the process, which has died out on the surface, in one or more 
glands, where the virus increases and may then be discharged 
upon the surface ; perhaps because the secretion of the virus is 
increased by local and general irritating influences, such as 
coitus and excesses in Baccho. 



86 Blenorrhcea of the Sexual Organs. 

The corpus cavernosum is also implicated in the more severe 
cases, its trabecular are swollen and more succulent, the erec- 
tile tissue is richer in blood, its meshes plugged by clots of 
fibrin in parts of the peripheral layers. 

Rokitansky makes the following statements concerning 
Menorrhagia : The catarrhal inflammation of the urethral 
mucous membrane as clap has a tendency to run a chronic 
course. It is either distributed quite uniformly over the ure- 
thra or it is very often confined to one or more places, either 
originally or in its subsequent course. Such spots are found 
everywhere up to the pars prostatica, but most frequently 
near the bulb and in the fossa navicularis. They are mani- 
fested by dark redness and swelling, occasionally (particularly 
in the fossa navicularis) by striking swelling of the mucous 
glands and formation of pus. The corpus spongiosum at these 
places (mainly in the inner layers, but sometimes in its entire 
thickness) is swollen, the size of its meshes is diminished, and 
it therefore contains less blood. This gives rise to a resisting 
ridge which is visible in the urethra. 

Although we are well informed concerning the macroscopi- 
cal changes in blenorrhcea, we know hardly anything of the 
finer microscopical changes, particularly concerning the situa- 
tion and distribution of the gonococci. 

Jullien (1 886) adopted the unproven theory that the blen- 
orrhagic process occurs chiefly in the lymph channels; he di- 
vided mucous membranes into those which are susceptible to 
blenorrhcea (with pavement epithelium, no papillae and a high 
network of sub-epithelial lymphatics), and those which are not 
susceptible (with cylindrical epithelium and a high vascular 
network). 

It is true that Bumm (1886) and Gersheim (1888) assume 
that gonococci are only able to enter mucous membranes with 
cylindrical epithelium and that pavement epithelium consti- 
tutes a complete obstacle to their immigration. Toulon (1889) 
disputes this statement, for the reason that he observed im- 
migration of gonococci between the pavement epithelium in 
gonorrhceal preputial folliculitis, and he regards their en- 
trance as dependent only on the width of interepithelial 
juice spaces. Toulon's findings were confirmed by Jadassohn 
(1890) and Fabry (1891). In 1887, Dinkier had noticed the en- 
trance of gonococci into the pavement epithelium of the cornea. 



Blenorrhcea of the Sexual Orga?is. 87 

Bockhart's (1883) previously mentioned case has not alone 
been the subject of attack with regard to its etiology, but the 
histological appearances also present certain peculiarities. 
Thus, the statement that the gonococci were situated in the 
nuclei of the migratory cells is entirely opposed to what is 
seen in blenorrhagic pus; and the pictures and descriptions of 
transverse sections of lymphatics filled with heaps of gonococci 
are so similar to Ehr lien's mast cells, that we must think of 
a mistake between the two, especially as no mention is made 
of mast cells, which are hardly ever absent in a specific inflam- 
mation. 

A partial substitute for the lacking histological details of 
blenorrhoea urethras is afforded by Bumm's (1886) investiga- 
tions on blenorrhoea conjunctivae neonatorum. 

According to Bumm the process in Menorrhagia, the com- 
bat between gonococci and the inflammatory products which 
endeavor to eliminate them, occurs in the following way: The 
infecting secretion conveys a certain number of gonococci to 
the mucous membrane. These penetrate the layer of epithe- 
lial cells and reach the papillary body of the mucous membrane, 
passing through and between the protoplasm and cement sub- 
stance of the epithelial elements. Swarms of white blood glob- 
ules emigrate at this time from the dilated capillary network 
which extends almost to the epithelial covering; they penetrate 
into the upper strata of the connective tissue, whence, laden 
with gonococci, they pass through the epithelium to the sur- 
face. The epithelial stratum, whose firmness is destroyed by 
the proliferation of cocci, is fissured by the stream of fluid ac- 
companying them, and raised in clumps; this may be aided by 
capillary hemorrhages between the epithelium and cellular 
tissue. 

The distribution of the cocci is confined to the superficial 
layers of the sub -epithelial cellular tissue, where they are ar- 
ranged between the fibres in rows or round colonies. While 
the micro-organisms increase in this manner in the outermost 
layers of the connective tissue, the inflammatory symptoms 
increase in intensity, and the round-cell infiltration finally 
occupies the entire papillary body, cell being closely applied to 
ceU. This furnishes the transition to the purulent stage, in 
which the majority of the gonococci are washed away by the 
abundant suppuration. After a variable time regeneration 



88 Blenorrhcea of the Sexual Organs. 

"begins from the remains of the original epithelium, and "by its 
extension puts an end to the further spread of the cocci in the 
tissues, while the migration of the pus cells, which cany off 
the remainder of the cocci, proceeds uninterruptedly. With 
the regeneration of the epithelium are usually associated pro- 
liferating processes, from the lowermost layers of which epi- 
thelial papillae grow into the connective tissue substratum. 
At this time the cocci have disappeared, with the aid of the 
pus cells, from the papillary bodies, and are only found in the 
upper layers of the epithelial covering. But if the fresh epi- 
thelial covering cannot withstand an" irruption of migrating 
round cells, induced by external irritants, its continuity will 
suffer and a new invasion of the papillary body with cocci will 
take place, i.e., a relapse occurs. During the latter part of 
the purulent stage and the entire muco-purulent stage the 
proliferation of gonococci takes place outside of the tissues, 
upon the surface of the epithelium and in the secretion. 

This description now requires certain corrections. Based 
upon Metschnikoffs theory it ascribes phagocytic power to 
the leucocytes, and assumes that deep down in the epithe- 
lium and in the upper layers of the papillary body the gono- 
cocci are incorporated by the active agency of the leucocytes 
and are carried to the surface. But Metschnikoffs theory is 
constantly encountering more and more opposition. 

Thus, Bumm (1839) himself claimed that the dense filling 
of many leucocytes with gonococci, the regular grouping in 
the plasma (which permitted the inference of intracellular 
proliferation) warranted us in inferring the penetration of 
the gonococci into the cells, intracellular proliferation, 
destruction of the cells, i.e., processes in which the 
gonococci play an active, the cells a passive part. Orcel 
(1887) has also shown that the union of the gonococci and 
cells takes place upon the free surface. After the pus of 
acute urethritis was removed by micturition and irrigation, 
he scraped the mucous membrane with horn curettes and 
found that the gonococci were always free. Neisser (1889) 
also agrees in this opinion. In opposition to Bumra's theory 
that the gonococci rapidly penetrate the epithelium and pro- 
liferate in the upper layers of the connective tissue, the 
opinion is beginning to prevail that the gonococci long remain 
upon the surface and proliferate exclusively upon and between 



Blenorrhoea of the Sexual Organs. 89 

the upper layers of epithelium. This opinion is based upon 
a series of anatomical findings. These include the investiga- 
tions of Toulon (1889), Jadassohn (1890), and Fabry (1891) on 
gonorrhceal para-urethritis, those of Rosinski (1891) on gonor- 
rheal aphthae, and those of Toulon (1893) on gonorrhceal 
Bartholinitis. In all these cases — and I have convinced my- 
self of the correctness of the findings by examination of several 
para-urethral gonorrhoeas — the gonococci proliferate exclusive- 
ly upon the surface of the pavement epithelium, form patches 
upon their uppermost layer, which appear on cross section as 
pairs of cocci arranged in a row alongside of one another. 
It is only in the interepithelial spaces that they penetrate 
between the cells into the deeper epithelial layers, and are 
here arranged behind one another; it is only in certain inter- 
epithelial spaces that they are arranged in small groups. 
According to Rosinski they penetrate most deeply into the 
epithelium in the buccal mucous membrane. They are never 
found in the connective tissue. We must not forget, how- 
ever, that we have to deal here with tissues of an essentially 
different structure from that of the urethra. The epithelium, 
which is usually a pavement epithelium of many layers, is 
very different from that of the urethra, which consists of a 
layer of cylindrical epithelium and one or two layers of tran- 
sition epithelium. 

In fact, Bumm's findings differ essentially from those just 
mentioned. Frisco's investigations (1892) on rectal gonor- 
rhoea do not coincide with those of gonorrhceal para-urethritis. 
In gonorrhceal conjunctivitis Bumm noticed rapid penetration 
of the epithelium and the presence of gonococci in the upper 
layers of the connective tissne. In his cases of rectal gonor- 
rhoea, Frisch found gonorrhoea in the glands, the periglandular 
connective tissue, and the entire mucosa as far as the muscu- 
lar coat. Finally, Wertheim (1892) found, on inoculation of 
gonococci cultures into the peritoneum, that they entered 
the connective tissue as far as the muscular coat inside of 
twent3 7 -four hours. 

The conjunctiva and rectum possess much more anatomi- 
cal similarity to the urethra than the latter does to the buccal 
mucous membrane and the para-urethral canals. 80 long as 
we are confined to inferences from analogy, it appears much 
more probable that the gonococci exhibit analogous conditions 



90 Blenorrhcea of the Sexual Organs. 

to the conjunctiva and rectum, so far as regards their en- 
trance and distribution. Anatomical investigations of gonor- 
rhoeal urethritis are still lacking. I have recently begun such 
investigations in Prof. Weichselbaum's Institute, but they are 
not yet concluded. I may here mention that in two cases, in 
which I examined the urethra thirty-eight hours and forty 
hours after infection, there was abundant infiltration of the 
epithelium and subepithelial connective tissue with leuco- 
cytes. Gonococci were found in small masses upon the surface 
of the cylindrical epithelium, but were especially numerous 
and often very deep in the lacunae and excretory ducts of 
Littre's glands. Their entrance into the connective tissue and 
penetration of the epithelium were not found at this early stage. 

The following facts prove, however, that in manj^ cases 
gonococci soon penetrate the epithelium and enter the con- 
nective tissue. 

In the first place Pelizzarri (1890) proved that para-urethral 
abscesses may be owing to gonococci. These abscesses are by 
no means rare in blenorrhceas which have not yet passed the 
second week since infection. 

Crippa (1893) has recently published two interesting cases 
from my hospital clinic, which belong to this category. Two 
patients came under observation, a week after infection, with 
the S3 T mptoms of acute blenorrhcea and oedema of the remain- 
der of the circumcised praepuce in the vicinity of the fraenu- 
lum and fossa navicularis. After careful cleansing I punctured 
and evacuated the oedema fluid. This contained gonococci, 
which were partty free, partly inclosed in the scant}^ leucocytes. 
Hence the gonococci had penetrated deeply into the subepi- 
thelial connective tissue a week after infection. 

In one case the gonococci were also found within leuco- 
cytes. Toulon (1889), Fabry (1891), and Frisch (1892) have 
also found pus cells laden with gonococci in sections of para- 
urethral and rectal gonorrhoea, This proves that the ^union 
of leucocytes and gonococci may take place in the tissues, and 
that the view of Orcel and Neisser does not always hold good. 

Treatment. 

There is hardly a branch of medicine which is so rich and 
in which so many and opposing recommendations, remedies 



Blenorrhoea of the Sexual Organs. 91 

and methods have been employed, as in the treatment of 
clap. Nevertheless, perhaps on account of this very fact, the 
treatment of the disease is one of the most thankless tasks in 
medicine. 

Not alone do external social conditions, the necessity for 
concealment, often impair the therapeutic results, and make 
the hygienic-dietetic prescriptions illusory, hut the struggle 
with the patient which the physician must undertake in order 
to keep the most powerful of all senses, the sexual sense, within 
the bounds necessary for recovery — a battle in which the phy- 
sician often succumbs — and the routine manner of treatment, 
are in great part at fault in the numerous bad results. So 
long as no change occurs in these respects, progress cannot be 
expected, and in addition to the complications a large percent- 
age of chronic urethritides must be attributed to the fault of 
the physician. So long as the physician regards every drop of 
pus at the meatus as synonymous with blenorrhoea and at once 
orders one of the usual injections with a clap syringe in a 
" purely reflex " manner, so long will the cure of blenorrhoea re- 
main an accident, which occurs despite the physician and not 
on account of his treatment. Thanks to the profession the 
matter has gone so far that many patients who suffer from 
urethritis visit the nearest apothecary in order to buy a solu- 
tion of zinc for injection, because they know that the physician 
will order nothing else. 

A positive diagnosis, accurate localization, gauging of the 
intensity of the symptoms and then precise directions accord- 
ing to certain indications are the only methods of effecting 
sure curative results. 

We have already said all that is necessary in regard to 
diagnosis. But I would like to emphasize the remark that, be- 
fore beginning treatment, the conscientious physician should 
convince himself of the nature of the disease and examine for 
gonococci. 

The second important question is the extent of the inflam- 
mation, whether we have to deal with simple anterior urethritis 
or whether this is complicated with posterior urethritis, inas- 
much as the treatment is essentially different in the two 
cases. 

Our anatomical studies have shown that the firm contrac- 
tion of the compressor urethral will make it impossible for fluids 



g2 Ble7iorrIi.ee a of the Sexual Organs, 

to pass from the pars anterior to the pars posterior. The 
ordinary method of injection with a clap syringe therefore 
carries the fluid into the pars anterior alone, and is useless in 
the treatment of posterior urethritis. 

Indeed, these injections are positively injurious in posterior 
urethritis. It is well known tha"t when urethritis is compli- 
cated by cystitis, epididymitis, prostatitis, even a very mild 
astringent injection into the urethra increases the intensity of 
the complicating- inflammation. But posterior urethritis is 
merely a complication of anterior urethritis and will also be 
aggravated by such treatment. Every physician who favors 
the routine treatment of every urethral suppuration with mild 
injections, will remember cases in practice in which the first 
injection was followed by some complication, usually epididy- 
mitis. Milton (1876) called special attention to this circum- 
stance. Bad syringes, awkwardness in making the injection, 
carelessness of the apothecary in making the fluid stronger 
than ordered, these are the reasons given by the physician to 
the patient in explanation of the mishap. But probably the 
patient is right in attributing the exacerbation to the physi- 
cian, inasmuch as a careful examination would have prevented 
the failure to recognize the posterior urethritis, which was in- 
tensified by the improper injection. 

The acuteness of the process must also be considered m 
every case. But localization is also important in this respect 
because, if a complicating posterior urethritis is present, we 
know that we have to deal with two processes of unequal acute- 
ness, and that those topical remedies which will diminish the 
inflammation if the latter is moderate, will increase it, on the 
other hand, if the inflammation is intense. 

We will first consider the possibility and methods of pre- 
venting blenorrhagic infection, then the hygiene and diet of 
the patients, the individual anti-blenorrhagics, and finally the 
methods and indications for their employment. 

Prophylaxis. — As a matter of course, the surest prophylac- 
tic measure against blenorrhagic infection is to avoid exposure. 
The small statistics furnished in considering infection show in 
which cases the danger of infection is greatest. But our social 
conditions make extra-marital coitus necessary for a large 
number of young people, and the question thus arises whether 
there is any means of preventing infection despite exposure. 



Blenorrhcea of the Sexual Organs. 93 

"We have previously mentioned the factors which favor infec- 
tion, and their avoidance alone constitutes a form of prophy- 
laxis. In suspicious cases coitus should be performed rapidly, 
without previous protracted excitement, and repetition of the 
act should be avoided. This does not prevent infection abso- 
lutely, because the introduction of the virus is still possible. 
Measures were therefore sought which would destroy the virus 
adherent to the glans or that had penetrated into the urethra. 
One of the oldest and most rational, viz., urination after coitus 
and washing of the glans with urine, was recommended by 
Johann de Gaddesden, Fallopius, Palmarius and Harrison. 
Guillelmus de Saliceto, Lanfrancus and Almenar mention 
washes of wine or vinegar. Torella thought the most certain 
means was the suction of the virus by other individuals. 
Magnardus recommended orange-blossom water for the rich, 
water in which iron had been cooled for the poor. Brassavolus 
and Boerhave suggested simple washes of cold water. Hier- 
onymus Montuus recommends that a freshly killed hen or 
frog be cut in two and applied to the penis. Ettmueller advised 
washes of turpentine and wine. Cataneus, Falk, Preval, Hun- 
ter and Spangenberg recommended corrosive sublimate and 
gray ointment. Warren, Peyrilhe, Oesterlen mention alkaline 
washes and injections, and Hausmann (1886) has recently ad- 
vised injections of a two per cent, solution of nitrate of silver. 
All these chemical agents are uncertain, because it is doubt- 
ful whether they can kill the virus or whether they even come 
in contact with it. Mechanical means are, therefore, more cer- 
tain and useful. Condom, an Englishman, prepared covers, 
made of the caecum of lambs, and rubbed with bran and almond 
oil, which were drawn over the penis during coitus. The in- 
ventor, who is said to have lived in England in the time of 
Charles II., obtained little honor from his discovery. He was 
so universally scorned and ridiculed that he was forced to 
change his name. But the covers devised by him have trans- 
mitted his name to a grateful posterity and are in general use 
at the present time under the name of condoms. When im- 
permeable and uninjured during coitus they furnish a greater 
safeguard than all chemical prophylactic measures. Unfor- 
tunately they are abused, and infection has been known to 
occur from previously used and insufficiently cleaned condoms, 
which were resold by prostitutes or dealers. 



94 



Blenorrhcea of the Sexual Organs. 



Hygiene, Diet. — After blenorrhoea has developed, the phy- 
sician has two objects in view — to keep at a distance all fac- 
tors which affect the course of the disease unfavorably, and 
to adopt curative and palliative measures. 





Fig. 4. 



Fig. 5. 



The first object is attained by regulation of the hygienic 
and dietetic conditions. 

This should not be regarded as trivial. In many cases, 
particularly in a first attack of anterior urethritis, strict regu- 
lation of these conditions would suffice to secure a rapid and 





Fig. 6. 



Fig. 7. 



favorable termination, as we can convince ourselves, particu- 
larly in hospital patients. Unfortunately not many patients, 
and least of all those in the better classes, are able to carry 
out such instructions strictly. For example rest in bed can 
hardly ever be secured. At all events all forced movements, 



Blenorrhoea of the Sexual Organs. 95 

such as running, gymnastics, dancing, exhausting and long- 
continued walks, should be prohibited. All violent passive 
movements, such as riding, driving, particularly on bad roads 
or in heavy wagons without springs, are equally injurious. 
Travelling on the railroad, with its slighter oscillating move- 
ments, is less harmful. In all cases we should recommend the 
wearing of a good suspensory. This is intended to elevate the 
external genitals, penis and scrotum without exerting pressure 
on them, to fix them against the lower part of the abdomen, 
and thus prevent the shaking which increases the inflammation. 
The number of suspensories is very great. All are serviceable 
which exercise uniform pressure and traction, i.e., those which 
not alone raise the external genitals, but also draw them 
against the body, the former \yy traction against the waist- 
band, the latter by traction against the perineum (Fig. 4). A 
good suspensory therefore possesses a waist-band, and perineal 
or thigh straps, as in those of Kohn, Neisser (Fig. 5), Ihle (Fig. 
6), Unna (Fig. ?). Those are bad which, like ordinary riding 
suspensories, simply raise the genitals, but leave this in the 
hands of the patient. By drawing too strongly on the straps 
the genitals are raised too far, and permanent compression of 
the perineal portion of the urethra results. This irritates the 
canal and is apt to cause stasis of the secretion. 

That coitus is to be forbidden is clear to the physician, but 
not always to the patient. Sexual excitement, resulting from 
lascivious thoughts, pictures, books, plays, and exciting female 
society, are also to be avoided. But the abstinence and the 
increased sexual irritabilit} 7 due to the blenorrhcea produce 
great sexual excitement despite the will of the patient. This 
is manifested by frequent erections and pollutions, which are 
extremely injurious. They should be combated by a cool, 
hard bed, regular evacuations from the bowels, and the use 
of antaphrodisiacs. Camphor, lupulin, potassium bromide and 
sodium bromide are useful. Camphor is also recommended 
externally, strewn upon cotton in the suspensory. The inter- 
nal administration is preferable. 

^ Camphorae rasa?, gr. iij. 

Mixt. gummosa?, § iij. 

S. 1 teaspoonful every 2 hours. 



96 Blenorrhcea of the Sexual Organs. 

Lupulin and the bromides are always given internally. We 
prescribe the following: 

3 Lupulini pur., gr. xv. 

Morphias muriat., gr. f . 

Sacch. alb., gr. xxx. 

M. f. pulv., div. in dos. x. 
S. 3 powders daily. 

^ Lupulini pur., gr. xv. 

Sacch. alb., gr. xxx. 

M. f. pulv., div. in dos. x. 
S. 3 powders daily. 

^ Lupulini, gr. xv. 

Camphorae, gr. iss. 

Extr. lupuli q. s. f . pill. x. 
S. 6 pills daily. 

The bromides are given morning and evening in gr. xv.-xxx. 
doses, but the following prescriptions are the most useful. 

R Natri. bromat., 3 iiss.-iv. 

Camphor ras., 

Lupulin, . . . . . aa gr. vij.-xxij. 

Mf. pulv. div. in clos. x. 

Put in waxed papers. 

S. 1 powder morning and evening. 

3 Camphor, monobromat., . . . . 3 i. 
Div. in dos. x. 
Put in capsules. 
S. 3 to 4 capsules daily. 

Antipyrin in doses of 15 to 30 grains is also recommended 
as an antaphrodisiac. 

Attention must also be paid to diet. Everything is to be 
avoided that makes digestion slow, causes constipation, irri- 
tates the genitalia directly and increases the inflammation. 

As regards the first point, all articles heavy of digestion, 
such as puddings, rice, cheese, are to be avoided. Food sea- 
soned with pepper, and curry, asparagus, highly salted and 
acid articles are stimulating and exciting. Very hearty, 
nutritious food acts the same way. 



Ble7torrhcea of the Sexual Organs. 97 

The fluids require special consideration. The close relation- 
ship of Venus and Bacchus is known not only in mythology. 
Carbonated drinks are especially to be avoided (champagne, 
beer, acid waters, such as soda water, Selters, Preblauer, Geiss- 
huebler, etc.). This is also true of heavy Italian, Spanish and 
English wines. It is best to forbid all alcoholic drinks. In 
many patients this command is shipwrecked on the cliff of 
secrecy. Now, I have always observed that after prolonged 
and complete abstinence even small amounts of alcohol are 
injurious, but that the bad effects are slight if the patient from 
the start accustoms his clap, I might say, to a moderate amount 
of alcohol and does not exceed this quantity. I therefore allow 
my patients from the beginning to take daily the same amount 
of light red wine. 

Many patients ask us concerning smoking. Bumstead (1883) 
regards it as injurious. It is true that those unaccustomed to 
smoking are sexually excited by it, but this is not true of habit- 
ual smokers. I therefore believe that it should not be abso- 
lutely interdicted. 

The attention of every patient should be called to the dan- 
ger of conveying the clap secretion to the eyes. Great care 
and cleanliness are indicated. It is best to allow him to wear 
some cotton in the preputial sac, which absorbs the discharge, 
and prevents soiling of the clothes; this should be frequently 
changed. Or the patient wears, attached to his suspensory 
and over the penis, a little bag which receives the discharge. 
Washing the hands after every manipulation of the genitals is 
strictly necessary. 

These are, in brief, the hygienic and dietetic rules, which 
the physician must adapt to each individual case. Thus, if 
there is deficiency rather than excess of sexual excitement, 
sedative treatment must be abandoned, in weak individuals 
tonic treatment is indicated, and the withdrawal of nourishing, 
easily digested food is out of place. 

Oversight of the Remedies. 

The most ancient theory concerning clap was that we had 
to deal with the secretion of increased and spoiled semen. 
Hence remedies were prescribed which were supposed to di- 
minish the production of semen, such as semen et folia rutae, 
mix pinese, semen anethi, lactuca, semina cannabis, plantago, 
origanum, etc. 



98 Blenorrhcea of the Sexual Organs. 

The conviction (which soon gained sway) that clap was an 
inflammatory process, and the discharge the result of ulcera- 
tion of the urethra and bladder, led to topical treatment, some- 
times to the most fantastic recommendations. Sedative and 
cooling- remedies, such as milk, whey, barley water, honey, and 
diluted vinegar, were used for injections. Very peculiar 
measures also appeared. Thus, we read in Hercules Saxonis 
(1597) : " Sciendum autem est, quod habui a quibusdam Vene- 
tis; dicunt, se a gonorrhoea statim curatos usu Veneris cum 
muliere ^Ethiope. Haec quoque scio, antiqua gonorrhoea 
plures fuisse liberatos, qui cum uxore, virgine rem habuere, 
sed tunc mulier inficitur." In the Richard manuscript of the 
thirteenth century discovered by Littre we read " Et nota, 
quod in magno clolore et tumore prodest, si in muliere diu, 
quando in coitu, moretur; vulva enini sugendo, mollificando 
et quasi purgando dolorem minuit et saniem attrahit." 

When the theory of the syphilitic nature of clap was pro- 
mulgated in the second half of the sixteenth century, the 
disease was subjected to antisyphilitic treatment, mercury, 
guaiac, sarsaparilla in large doses and drastic purgatives. 

The change in the etiological views at the beginning of this 
century caused a change in treatment, and clap, recognized as 
a local disease, was treated locally. Some of the remedies 
were empirical, others, like the astringents, belonged to the 
group of antiphlogistic s. 

Advances in therapeutics might have been expected from 
the most recent investigations in etiology, especially from the 
discovery of the gonococcus. Unfortunately these expectations 
were not fulfilled. A few writers have made pure cultures of 
the gonococcus, and studied the effect of various remedies on 
contagiousness, growth and vital conditions, but these labori- 
ous investigations have hitherto had no practical value. These 
investigations do not always show clearly that the writers 
really experimented with the gonococcus, and then the growth 
of the cocci upon our artificial nutrient medium is so pre- 
carious and easily disturbed, that we cannot infer that those 
doses and remedies which prevent the growth of the pure cult- 
ure, will have a similar or approximately similar effect upon 
the development on the good soil of the urethral mucous mem- 
brane. Until we possess an artificial nutrient medium which 



Blenorrlicea of tJie Sexual Organs. 99 

offers the gonococci the same favorable conditions as the ure- 
thral mucous membrane, we can arrive at no conclusion on 
this question. But it cannot be held that the discovery of the 
gonococci has been entirely valueless as regards treatment. 
They furnish us with positive knowledge concerning two thera- 
peutically important data — the diagnosis and the virulence of 
the secretion, the duration of treatment. 

Friedheim (1889) and Neisser (1889) have recently rec- 
ommended nitrate of silver as a direct antibacterial remedy, 
but we do not agree unqualifiedly w T ith their conclusions. 
Neisser mentions the following conditions of rational treat- 
ment: 1, the remedy must kill the gonococci; 2, it should 
not injure the mucous membrane; 3, it should not increase 
the inflammation. Nitrate of silver does not meet all these 
indications. According to Jerosch (1889) the drug, in solutions 
of 1 : 1000, kills the germ in two to three minutes, but this only 
holds good of cultures. Like corrosive sublimate, it is de- 
composed b} 7 pus and blood and loses much of its efficacy. 
Thus, Jerosch states that, on admixture with serum, 2 per 
cent, solutions must act for five minutes before they are really 
parasiticide. Moreover, it is probable that different germs 
will react differently to nitrate of silver. Thus, Oppenheimer's 
supposed cultures of gonococci were only affected by 2 per 
cent, solutions of nitrate of silver. Although this drug will 
not produce lesions of the mucous membrane, it is a powerful 
irritant. Even in weak solutions (1 : 2000 to 1000) which are 
no longer positively parasiticide, the mucous membrane is 
irritated to such an extent that I do not regard its applica- 
tion as advisable in recent blenorrhceas. Ammonium sulfo- 
ichthyolium, recommended by Koester (1890), and Jadassohn 
(1892), is more serviceable because less irritating, although it 
is not a perfectly reliable parasiticide. 

Corresponding to the local nature of the process, all our 
remedies are local, and differ only in so far as the topical action 
is effected, in one group, indirectly by internal administration, 
directly, in the other, by topical application. The internal 
remedies belong to the category of balsams and ethereal oils, 
or they are alkaloids, or finally mineral substances, particu- 
larly alkalies. 

The ethereal oils and balsams occupy the most prominent 



ioo Blenorr/icea of the Sexual Organs. 

place. This is particularly true of copaiba balsam, derived 
from various leguminosae of the species copaifera, particularly 
copaifera officinalis and guyanensis. It forms a thick, light 
to brownish yellow, clear, sticky mass like thickened oil, with a 
peculiar resinous odor and a bad taste. It was first given in- 
ternally by Markgraf and Pison (1648) and introduced into the 
treatment of venereal diseases by Daniel Turner (1729) and J. 
Thorn (1827). It is given in doses of 15 to 20 drops on sugar. 
Unfortunately the nauseous taste is then very pronounced, 
and the attempt was therefore made to conceal this or to give 
it in another form. From the desire to conceal the bad taste 
sprang Chopart's potion, which is still used in France : 

$ Balsami copal vae, 
Spir. vin. rectific, 
Syr. tolutan., 
Aq. menthae, 

Aq. naphae, aa § ij. 

Spirit nitric, 3 ij. 

S. 3 to 6 tablespoonfuls daily. 

Ricord modified and simplified this prescription : 
I£ Balsami copaivae, 

Syr. diacodii, 

Syr. tolutan., aa | j. 

Aq. menthge, 1 ij. 

Aq. naphae, 3 hss. 

Gummi arabic q. s. f. emulsion 

S. 3 to 9 tablespoonfuls daily. 

The following similar mixtures are used f requentry : 

$ Bals. copaiv., . . » . . % j. 

Spirit, nitric, 3 ij. 

Tinct. opii spl., gtt xxx. 

S. 20 drops 2 to 4 times daily. 

$ Bals. copaiv., 3 iij. 

Vitell. ovi tria c. aq. fontis, . . § v. 

Aq. cinnamon., f j. 

Syr. cinnamon., § ss. 

S. 1 ta blespoonful every 3 hours. 



Blenorrhcea of the Sexual Organs. 101 

The bad taste of these mixtures induced Lagneau and Vel- 
peau to administer the balsam in enemata. 

R Bals. copaiv., 5 ss. 

Vitelli ovi I. 

Extr. opii aq gtt. j. 

Decoct, sem. lini. 1 vj. 

S. For one enema. 

Wehner prescribed the remedy in suppositories : 
3 Bals. copaiv., 1 v. 

Pulv. opii, gr. iv. 

Butyr. cacao, 

Spermaceti, . . . . . aa | iss. 

Cerae alb., . gr. xlv. 

F. supposit. No. xii. 

S. One suppository morning and evening. 

All these, in part impracticable, methods of administration, 
became superfluous when Favrot and Mothe began the use of 
gelatine capsules, filled with 5 to 10 drops of the balsam, per- 
mitting its entrance into the stomach without its nauseating 
effect. The copaiba is given in this way at the present time, 
3 to 6 capsules being taken daily. 

Bicord (1849) and Roquelle (1854) showed that it merely 
acts locally, by passing into the urine. The latter, saturated 
with the balsam or its disassimilative products, passes through 
the urethra, and thus produces its action. Both these writers 
treated clap patients who suffered from urethral fistula, with 
copaiba internally. The portion of the urethra situated be- 
hind the fistula, and which was constantly washed by the urine, 
recovered, the portion in front of the fistula remained blenor- 
rhagic and did not heal until injections of the patient's urine 
were made into it. Ricord then administered copaiba to a 
patient in his clinic who was not suffering from blenorrhoea, 
and injected a few clap patients with his urine. This urine 
proved effective, a distinct evidence of the topical action of the 
balsam. Weickart (1860) first studied the form in which the 
copaiba enters the urine. He showed that the resinous acid, 
the copaivic acid, unites in the circulation with the alkalies, 
and this enters the urine dissolved as sodium copaivate. 



102 BlenorrJioca of tJie Sexual Organs. 

In addition the urine contains the ethereal oil, which gives 
it the peculiar odor of violets. If a mineral acid is added 
to urine containing' sodium copaivate in solution, a whitish 
flocculent precipitate, very similar to albumin, is obtained. 
This precipitate induced many observers to really suspect 
albuminuria and led to the statement that the balsam may 
give rise to nephritis, an accusation which was repeated 
in 1872 by Tarnowsky. The precipitate consists of the co- 
paivic acid, which is freed by the mineral acid from its com- 
bination with the soda, and is soluble in an excess of the acid. 
Rocco da Luca and Amato (1884) have studied the action of 
copaivic acid and oil of copaiba on blenorrhcea, and have 
come to the conclusion that neither of these constituents sepa- 
rately has the same effect as their combination in the balsam. 
Like Quincke (1883) they showed that, on the administration 
of the pure oil, this passes into the urine as an easily decom- 
posed salt. On the addition of mineral acids to such urine the 
acid is set free and imparts a purplish-reel color, which Quincke 
calls copaiba red. 

Unfortunately copaiba sometimes produces certain inci- 
dental effects which interfere with its administration or render 
this impossible. Thus, it is absorbed with difficulty, produces 
indigestion after protracted use, and this may increase to 
severe gastro-intestinal catarrh, unless care is exercised. Less 
important, but very alarming to the patient, are the phenom- 
ena on the integument, which sometimes develop after the first 
dose. These consist of eruptions, belonging to the class of 
angioneuroses, such as erythema or roseola, a papular ery- 
thema, or, more rarely, urticaria or purpura. The most fre- 
quent of these polymorphous eruptions are patches of circum- 
scribed redness, whose color may also vary from dark violet 
to yellow; they become confluent, their size changes rapidly 
and they usually disappear rapidly without subjective symp- 
toms. In many cases the first dose alone is followed by the 
eruption, which disappears despite the continuance of the 
medication; in other cases the eruption increases with the 
further administration. If the eruption is an urticaria, gas- 
tric disturbances and pruritus are usually present. The symp- 
toms generally disappear spontaneously as soon as the bal- 
sam is discontinued. 



Blenorrhoea of the Sexual Organs. 103 

Cubebs, the fruit of piper methysticum, like pepper-corns 
in size and shape, are blackish-green grains with a pedicle. It 
was recommended freshly powdered as an anti-blenorrhagic 
after Crawford (1818), an English army surgeon, had learned 
its use in India, where it is a popular remedy. It is less effect- 
ive than copaiba, but fell into discredit chiefly because it was 
given in such enormous doses. Thus Puche ordered, from the 
beginning of blenorrhoea, 3 iiss. of the powder on the first day, 
and then a daily increase of 3 iiss. until the discharge ceased. 
Powdered cubebs is given in gr. xv. to xlv. doses two or three 
times daily in wafers, or the ethereal extract, cubebin, is given 
in one-tenth this dose. Combinations of cubebs, especially 
with copabia, are also popular. For example : 

^ Pulv. cubeb., 3 j. 

Alumi, 3 ijo 

Root sambuci q. s. f. electuarium, 
S. 3 to 4 teaspoonfuls daily. 

5 Pulv. cubeb., 

Bals. copaiv., aa § ss. 

Gummi arab., 3 ij. 

Aq. cinnamon., § iv. 

Syr. cort. aurant., 3 j. 

S. 1 teaspoonful t. i. d. 

Velpeau (1826), Fenoglio (1846), Caudmont (1861), were 
special advocates of the combination of copaiba and cubebs, 
to which the} 7 attributed greater efficacy than to each one 
singly. Sigmund also favored the following prescription : 

5 Pulv. cubeb., 

Bals. copaiv., . . . . . aa gr. xlv. 
Extr. gentian q. s. f. pill xxx. 
S. 8 to 9 pills daily. 

The incidental effects of cubebs are not by far as disagree- 
able as those of copaiva, although it sometimes produces gas- 
tritis or urticaria. 

Sandal-wood oil, acquired by distillation from syrium 
myrtifolium, was recommended by Henderson (1865) and 
Panas (1865). Although it was repeatedly recommended in 



104 Blenorrhcea of the Sexual Organs. 

France, for example by Nirgon and Pathault, it found 
favor very late in German}^. It was only through the recom- 
mendations of Posner (1886), Meyer (1886), Letzel (1886), Ros- 
enberg (1887), and Linhardt (1887), that it has secured general 
recognition. This is so much more deserved because, while 
equal in efficacy to copaiba, it does not possess the disagreea- 
ble incidental effects of the latter. It rarely causes gastritis, 
but in a few cases it has produced symptoms of renal congestion, 
which demand a certain degree of caution. It is given in doses 
of gtt. iij.-x. in gelatine capsules t. i. d., or 

I£ 01. santali, 1 ss. 

01. menth. pip., gtt. viij. 

S. 15 to 20 drops 3 or 4 times daily. 

Peruvian balsam and balsam of tolu have also been recom- 
mended, but only employed for a short time, and are inferior 
to the others in their effect. 

Vidal (1877) recommended gurjun balsam, which had been 
previously recommended by Henderson (1865) as wood oil. 
Yidal prescribes: 

5 Balsam, gurjun., 

Pulv. gummi arab., . . . . aa 3 j. 

Syr. simpl., 3 iij. 

Infus. anis. stellat., 3 x. 

S. For one day. 

Matico, obtained from piper angustifolium, was recom- 
mended by Favrat (1861), partly alone, partly in combination 
with copaiba. Infusions of the leaves were also used for in- 
jections. Scarenzio, Sigmund and Jullien deny any curative 
properties to this drug. 

Turpentine, a very effective remedy but difficult of diges- 
tion, and w T hich was employed by Swediaur (1798), is usually 
given in combination with cubebs, rarely alone. 

Tar preparations and derivatives have also been used, but 
only with temporary success. Riemslagh (1862) advised aqua 
picea internally, Zeissl (1874) inhalations of oleum sethereum' 
pini, Bremond (1874) turpentine vapor baths, Barton (1886) 
creasote. 



Blenorrhoea of the Sexual Organs. 1 05 

Kawa-kawa, the root of piper methysticum, was recom- 
mended by Dupouy (1876). He digests gr. lxxv. of the finely 
cut root in 1 quart of water, filters and administers the gray 
aromatic fluid. Blackerby (1881) prescribes: 

^ Ext. kawa-kawa fid., § iij. 

Spirit 33th. nitros., 3 ix. 

Syr. simpl., 3 xviij. 

S. 3 tablespoonfuls daily. 

Schutt (1883) prescribes : 

fy Ext. kawa-kawa fid., 3 ss. 

Ext. rhus. aromat., 3 ij. 

Bals. copaiv., f ss. 

Tinct. cubeb., § ij. 

S. 4 teaspoonfuls daily. 

Sanne (1886) orders extract of kawa-kawa in pills of gr. iss., 
4 to 8 pills daily. 

Among* other remedies we may mention vinum colchicum 
opiatum, tinctura colchici, digitalis, hydrastis canadensis, ar- 
butus unedo, gelsemium sempervirens, baccae myrtillorum, 
asclepias incarnata, tincture of aloes, hasheesh, amaranthus 
spinosa, Jamaica dogwood, tinctura sierras salviae. 

Finally, sal ammoniac has been recommended internally 
in large doses, potassium bromide in doses of 3 j.-iss. daily, 
potassium chlorate gr. xlv. daily, and sodium salicylate 3 iss. 
daily. 

Dreyfuss (1890), Sahli (1890), Girard (1890), Lane (1890) and 
Hicks (1890) recommend salol (3ij. in twenty-four hours) 
either alone or in combination with antipyrin. 

Local Eemedies. 

Instrumental. — Local applications or urethral injections 
have been employed in clap since the earliest times, but they 
were always used merely as an adjuvant to the internal and 
general treatment. The syringes used were similar to those 
now employed. Blegny (1683) portrayed one which cannot be 
distinguished from one of to-day. Hahnemann used small 
syphons, Weikard used syringes with a flat end and a small 



106 BlenorrJioea of the Sexual Organs. 

central opening 1 , which was applied flat against the opening of 
the urethra. Swediaur (1798) gives directions concerning the 
construction of a good syringe which differ in no respect from 
those furnished by Sigmund. Other apparatus was also in- 
vented whose object was to render it possible to confine the 
penetration of fluid to certain parts of the urethra, or to allow 
it to enter with certainty the deep parts of the canal. To this 
class belongs Langlebert's syringe, "a jet recurrent" (Fig. 8). 
To an ordinary syringe is fitted a canula of platinum or bone, 
5 to 6 cm. long, which terminates at the free end in an olive- 
shaped enlargement. The lumen of the canula opens immedi- 
ately behind the olive in four small openings, which run ob- 
liquely backwards from within and anteriorly. The fluid 
always makes its wa} r alongside the canula to the outside and 
never penetrates deeper than the olive. Bron's (1858) quite 




Fig. 8. 

complicated apparatus was devised in order to apply the fluid 
to a single definite part of the urethra. It consists of a cathe- 
ter with three openings, situated 2.5 cm. from one another. 
The first and last openings are concealed by rubber rings, 
which can be expanded through them. The middle opening is 
free and serves for the injection, while the rubber rings are 
distended, and occlude a portion of the urethra anteriorly 
and posteriorly. Diday (1858) was not the first one who knew 
that injections with the ordinary syringe did not penetrate 
farther than the bulb, but his plan was the first which secured 
irrigation of the entire urethra. While the bladder was 
moderately full he passed a narrow elastic catheter into the 
urethra until the urine began to flow and then withdrew it 
until the flow ceased. The eye of the catheter is then situated 
in the pars prostatica in front of the ostium vesicae. A syringe 
is then fixed to the outer end of the catheter, and the injection 
made while the latter is slowly withdrawn. So long- as the 
eye of the catheter is situated behind the compressor, the in- 
jection fluid passes through the pars posterior into the bladder; 
when it is situated in front of the compressor, it flows through 



Blenorrhcea of the Sexual Organs. 



107 



the pars anterior to the meatus and comes in contact with the 
entire urethra. Guyon's (1867) urethral syringe (Fig*. 9) also 
permits applications to definite parts of the urethra. It consists 







Fig. 




Fig. 10. 



of a large Pravaz syringe whose piston is moved by turning- a 
screw. A half turn corresponds to a drop. The anterior, 
conical, canula-like end of the syringe fits accurately, by 



io8 



Blenorrhcea of the Sexual Organs. 



means of the thread of a screw, into a rubber olive-tipped 
bougie, which has a fine canal terminating at the tip in a small 
central opening-. The bougie is introduced into the urethra 
and the fluid deposited by drops in the canal. Durham used a 
clysopump-like syringe. Prince devised a syringe with cathe- 
ter-like tips, which could be screwed on, and which possessed 
an olive tip with lateral openings behind the latter. Milton is 
thoroughly convinced that injections with the ordinary syringes 
never reach the pars posterior. Thus we read on page 115 of 
his discussion on the development of strictures as the result of 
injections : " But I think I have evidence enough in my posses- 
sion to prove that injections, as ordinarily employed, never 
reach the part where most of these strictures begin — that is to 




Fig. 11. 

say, the bulb of the urethra and its immediate vicinity." He 
also emphasizes the fact that he has never been able to inject 
fluid into the bladder by a simple injection in the urethra, even 
with the aid of force. 

With a correct view of these relations Milton devised his 
" long urethral syringe " (Fig. 10), a catheter, which is intro- 
duced into the urethra as far as the bulb, pars membranacea 
or prostatica, and to whose outer end a syringe, with a capac- 
ity of 200 cm., is attached. Burckhardt and Vajda devised 
complicated apparatus, which are hardly ever used, for the 
purpose of injecting fluid under high pressure, which could be 
regulated at will. 

Balmanno Squire (1882) describes a simple and convenient 
syringe (Fig. 11). It consist of a flat, rounded, rubber syringe; 
two metallic plates, inserted in the two flat sides of the syringe 
and of the same size, make it possible to empty this handy bal- 
loon syringe completely. Ultzmann (1883) describes two in- 



Blenorrhoea of the Sexual Organs. 



109 



strciments for irrigation and injection of the posteria urethra. 
The first, the irrigation catheter (Fig. 12), consists of a silver 
catheter, 16 cm. long, of medium curve, 14 to 16 Charriere, with 
the vesical end smooth and rounded. It contains either sieve- 




r 




Fig. 12. 



Fig. 13. 



like openings or four lateral fissures, placed crosswise, 1 cm. 
long, 2 mm. wide- The extra-vesical part carries a disk of hard 
rubber, and a mark upon it shows the direction of the tip of 
the catheter. To the disk is fastened a soft-rubber tube, about 
20 cm. long, which connects with an ordinary surgical syringe. 
The irrigation catheter is introduced into the urethra while 



no 



Blenorrhoea of the Sexual Organs. 



the patient is in the dorsal position, until the penis makes an 
angle of 120° with the horizontal, the surface of the abdomen. 
The tip is then in the posterior portion of the pars mem- 




Fig. 14. 



branacea. The fluid driven by the syringe into the catheter 
must now pass the pars prostatica and enter the bladder, but 
cannot regurgitate alongside the catheter. Upon removing 
the syringe the fluid should not escape from the catheter, 
as this would show that the tip is situated in the bladder. 



Blenorrhcea of the Sexual Organs. 1 1 1 

The urethral injector (Fig-. 13) also consists of a silver catheter 
of medium curve, 16 cm. long", with a calibre of 14 to 16 Char- 
riere. At the extra-vesical end is an addition of hard rubber 
into which fits a Pravaz syringe. On introducing- the instru- 
ment into the urethra the tip of the catheter enters the pars 
prostatica, when it makes an angle of 135° to the horizontal 
(Fig*. 14). Aubert, Bourgeois, and Eraud recommend that in- 
jections in the pars anterior should always be made by pass- 
ing- a narrow elastic catheter as far as the bulb and injecting 
throug-h this. In order to reg-ulate the pressure of the injected 
fluid, Petersen and I recommended an apparatus coincidently. 
Instead of a syring-e Petersen recommends a rubber tube with 
an olive tip at one end, a curved glass tube at the other end. 
This glass tube is dipped into a vessel and the fluid enters 
the tube by syphon action. The pressure is regulated by 
raising and lowering the vessel. 

My apparatus (Fig. 15) consists of a syringe, with a capac- 
ity of 300 to 500 cm., which is hung parallel to the wall and 
vertical, at about half a man's height. The lower end carries 
a firm rubber tube about 1 m. long, to which is attached the 
pear-shaped tip, which can be closed by a stop-cock. The 
upper end, instead of being fastened by a screw, simply has a 
cover which is perforated by the piston-rod, and which can be 
put on like the cover of a box. The piston-rod terminates above 
in a flat disk, instead of a ring. The syringe is filled in the 
usual way, by suction through the tube and tip, and the latter 
must therefore be made of firm material in order to prevent 
compression by the pressure of the atmosphere. On account of 
the large dimensions of the syringe one filling suffices for many 
injections. The apparatus has a double use. It serves as a 
simple irrigator if the piston and cover are removed after fill- 
ing. If the pressure is to be increased the piston and cover 
are allowed to remain and weights are placed upon the disk 
attached to the piston rod. I begin usually with \ kilo and 
increase successively to 3 to 5 kilo. When the piston has a 
diameter of 4 cm. and the weights amount to 3 to 5 kilo the 
pressure of the column of fluid on each square centimeter of 
the urethral mucous membrane is 240 to 400 gm., and always 
remains the same so long as the simple apparatus works well. 
Hitches are not apt to occur, except from dryness of the piston, 
which is soon relieved by oiling. 



112 



Blenorrhcea of the Sexual Organs. 



Other irrigation apparatus for the anterior and posterior 
urethra have been devised by Lohnstein, Schuetze, Lanz and 
Burckhardt. 

Lohnstein-Zuelzer's apparatus consists of a hat-shaped 




Fig. 15. 

bell which covers the glans, and which contains two concen- 
tric tubes. The inner one is connected with the irrigator, the 
outer contains slit-shaped openings for the escape of the fluid. 
The chief object of the apparatus is to cleanse the urethra by 
irrigation with a six-per-cent. solution of sodium chloride pre- 
paratory to further treatment. Schuetze's instrument is con- 
structed on the principle of the Fritsch-Bozemann uterine 
catheter. 

Lanz's apparatus (Fig. 16) consists of two concentric tubes. 
The inner one ends just in front of the tip of the outer tube. 



Blenorrhcea of the Sexual Organs. 



i i 



This is a thin metallic catheter whose walls are converted 
into threads by broad and long* slits which extend almost to 
the visceral extremity and are provided at the tip with a cap. 




Fig. 16. 



Fig. 17. 



The inner tube is connected with the irrigator, the entering 
fluid flows back from the inner wall of the cap of the outer 
tube, and, flowing- backward, washes the mucous membrane 
which projects inward through the slits. 



H4 Blenorrhoea of the Sexual Organs. 

Burckhardt's injection apparatus (Fig-. 17) consists of a 
narrow catheter with an olive-shaped tip. The part covered 
by the olive has a number of perforations. The fluid, in- 
jected through the catheter, escapes through the openings, 
rebounds from the inner surface of the olive and flowing back- 
wards washes the urethral mucous membrane. 

We need say very little concerning the ordinary clap 
syringes (Fig. 18). They should have a capacity of at least 6 
c.cm., and at the most of 10 c.cm. The piston must fit snugly, 
and hence syringes made of hard rubber or tin are preferable 
to those of glass (in which the lumen is apt to be uneven) with 
a cork piston. The tip should terminate in a gradually dimin- 
ishing- cone, which will entirely close a large as well as a small 
meatus, and will only enter a few millimeters. Pear-shaped 
or duck-bill-shaped tips, which penetrate far into the urethra 
and close the meatus imperfectly, are to be avoided. 

The S3 T ringe must also be well oiled so that it works 
smoothly, and the disadvantag-es of a jerky, intermittent move- 
ment of the piston avoided. 

Medicaments. — The number of remedies used for injections 
is endless. 

None has been employed so much, has been extolled and 
deprecated so much, as nitrate of silver, the most effective of 
all. Johnston and Barklet recommended it in America, and 
in Europe it was first introduced by Carmichael (1818) and 
Serre. It was soon employed not alone for the methodical 
treatment of clap, but also for the so-called abortive treatment. 
We will discuss this remedy later and will here simply state 
that the strength varies between 1.0:30.0 and 0.10 to 250.0 of 
water, according as it is used in abortive or methodical treat- 
ment. 

Corrosive sublimate has long been used, and is now recom- 
mended anew, on account of its antiparasitic action. Musi- 
tanus, Malon, Gardane recommended it, and it was a favorite 
remedy of Hunter, who prescribed solutions of gr. ij. to § viij. 
of water. Girtanner and W T allace also used it. It then fell 
into disuse but was restored to temporary favor by Mueller von 
Berneck (1846), but it is only since Fantini (1861),Bruck (1876), 
and particularly since our new parasitological knowledge that 
it has come into more g-eneral favor. When it was known 
that solutions of 1 :3000 to 4000 were sure parasiticides, these 






Blenorrhcea of the Sexual Organs. 115 

were adopted. But Barduzzi (1884), Keyes (1884) and Auspitz 
(1879) soon were heard in opposition, claiming- that such solu- 
tions produced violent irritative symptoms. The more recent 
advocates of corrosive sublimate, such as Chameron (1884) and 
Vanderpool (1886) recommend solutions of 1 : 20000. 

Sulphate, acetate and sulfo-carbolate of zinc, the former 
recommended by B. Bell, Lisfranc, Blancard and Large, the 
latter by Henry, have become lasting additions to our arma- 
mentarium, and are successfully used at the present time in 
solutions of gr. iij.-xv. to § iij. 

This is also true of permanganate of potash, which was first 
used by Rich (1864) in the enormous dose of gr. vj. to 1 j., and 
then lapsed into oblivion. It was restored to favor by the 
recommendation of Bresgen (1867) and is now prescribed in 
solutions of gr. -J-iss. : 3 iij. 

Acetate of lead, recommended by Bertrandi (1790) was 
favored by Ricord, particularly in combination with sulphate 
of zinc. This prescription, still known as Ricord's injection, has 
many advocates. The following- is the original prescription : 

$ Zinci sulphat., gr. xv. 

Plumbi acetic, . . . . . . gr. xxx. 

Aq. rosae, . . ... . . § vj. 

Tinct. catechu, 

Tinct. opii., aa 3 j. 

S. To be well shaken and injected. 

Sigmund often prescribed acetate of lead in the proportion 
of gr. xxx. : 3 iij. of water. 

Chloride of zinc has been recommended by Lloyd (1850), 
Debeney (1851) and Bumstead (1867). The latter dissolves 
3 hss. of the chloride in | ss. of water, and injects two to eight 
drops to a teaspoonful of water three times a day. 

Among the alkalies caustic potash 1 : 200 was recom- 
mended by Fordyce (1758) and Warren (1771), and a solution 
of ammonia by Peyrilhe (1786). 

Subnitrate of bismuth, first recommended by Caby (1854), 
is still often used in the proportion of 2.0:100. Recently 
there has been much opposition, particularly by Eraud (1886), 
to this remedy, which is insoluble in water, precipitates in the 
urethra, stops up Morgagni's lacunae, and leads to the develop- 
ment of urethral calculi. 



1 1 6 Blenorrhoea of the Sexual Organs. 

Chloroform, recommended by Venot (1850) was used for 
injections, especially by Parona, in the proportion of 1 :100 to 
200, but produces violent irritative symptoms. This is also 
true of chloral hydrate, which was used by Lecchini (1874) in 
a 1 per cent, solution, by Pasqua (1880) in a 2 per cent, solu- 
tion. 

Gazeau used sulphate of cadmium in solutions of 1: 1000 to 
2000. 

Chloride of iron in solution of 1 :100, bicarbonate of soda, 1 
to 100, potassium bromide 5 :150, and in 1 to 3 per cent, solu- 
tions have also been used. 

Tannin alone or as tannin-glycerine was recommended by 
Lange, Deneffe and Hill, tincture of iodine by Masurel and 
Paquet. The latter injects tincture of iodine 5.0 in aqua 
laurocerasi 20.0. Zeller (1875) recommends : 

5 Tinct. catechu, 1 j.-iss. 

Glycerini, 3 j. 

Tinct. iodin., gtt. xv.-xxx. 

Aq. rosarum, § vj. 

The conviction that copaiba acts locally led Oates, Engel- 
hart and Marchal to inject it in various mixtures. For the 
same reason Langlebert used eau destillee de copahu. 

Among* other remedies we may mention oil of eucalyptus, 
iodoform as injection in a mucilaginous mixture or in bougies. 
Campana prescribes : 

$ Iodoform., . . . . . 3 v. 

Acid carbolic, gr. iss. 

Glycerine, $ iiss. 

Aq. clestil., 3 v. 

S. For injection. 

Haberkorn and Delorme inject quinine. The latter pre- 
scribes : 

3 Quin. sulph., gr. xv. 

Acid sulph. q. s. ad solut., 

Aq. destil., § iiss. 

Glycerine, 3 vj. 

Resorcin is recommended by Muenich and Letzel in a 2 to 
4 per cent, solution, Goll recommends thallin sulphate in 1 to 



Blenorrhcea of the Sexual Organs, 1 1 7 

3 per cent, solutions. Blackerby injects fld. extr. yerba reuma 
35.0, water 175.0. Schutt prescribes: 

5- Hydrastin muriat., gr. ix. 

Iodoform pulv., gr. iij. 

Glycerine, 3 j. 

Inf. sassafras, 3 ij. 

S. Four times a day. 

Solid powders, partly inert, partly astringent, such as sub- 
nitrate of bismuth, oxide of zinc and iodoform have been 
recommended by Malles and Cattaneo to be blown into the 
urethra by means of special apparatus. The disadvantages 
of the severe irritation and the formation of concretions soon 
led to the abandonment of such methods. 

Finally, we may mention that Ricord, Malgaigne, Desruel- 
les and Tanchon not alone injected astringents into the urethra, 
but also introduced, by means of sounds, pledgets of lint soaked 
with the fluids and allowed them to remain several hours. 

The " antrophores " recommended recently by Nachtigall, 
Lohnstein, Istamanoff and Bessard owe their development to 
the same principle. They consist of thin, flexible wire spirals 
with a smoothly polished button at one end, a ring, which pre- 
vents a complete entrance into the urethra, at the other end. 
The wire spiral, covered with shellac, receives a coating by 
dipping in medicated glycerin. This coating is solid at ordi- 
nary temperatures but melts in the urethra. The gelatin 
contains three to five per cent, thallin, or two to three per cent, 
sulphate of zinc, nitrate of silver, iodoform, etc. The antro- 
phores were used indiscriminately in the different stages of 
acute and chronic blenorrhoea, so that it is not astonishing that 
their effect did not equal the expectations raised. When em- 
ployed in time they exert an undoubted good effect. Lang's 
elastic drains, with a medicated covering, are similar in prin- 
ciple to the antrophores. 

Methods. 

We will now enter upon the explanation of the various 
methods which have been used for the cure of urethritis. 

Before discussing the application of individual remedies, it 



n8 Blenorrhcea of the Sexual Organs. 

would be desirable to examine into their mode of action, but 
unfortunately this can only be done in an imperfect manner. 
The urethral suppuration, the main S3 T mptom of the gonor- 
rheal process, is merely a phenomenon of resistance on the 
part of the organism. The gonococci enter the urethra, where 
they find a suitable soil and proceed to increase. This colon- 
ization is not tolerated by the organism, which begins a 
combat with the virus; the numerous migrating lymph cells 
become laden with gonococci and endeavor to carry them off. 
This struggle continues until the last gonococcus has been 
destroyed or removed. The suppuration and inflammation are 
therefore necessary to the cure of the affection, so long as they 
remain within certain bounds. If we do not disturb these proc- 
esses and no unfavorable external influences intensify the in- 
flammation, it will run its course spontaneously within a cer- 
tain period. We know that an anterior urethritis, which runs 
a typical course, lasts five to six weeks. There is one method 
of treatment, the expectant plan, which is confined to allowing 
the struggle between the gonococci and the tissues to termi- 
nate uninfluenced, and to merely keeping away all noxa which 
might produce useless or even injurious intensification of the 
otherwise beneficial inflammation. 

A shortening of the course of the disease can only be 
effected by action upon the gonococci. It is senseless to at- 
tempt to shorten the course of the inflammation so long as the 
inflammation-producers, the gonococci, are still present. 

The gonococci can be acted upon in two ways, either di- 
rectly, by destroying them, or indirectly, by producing a 
change in their soil, the mucous membrane, which is unfavor- 
able to their proliferation. 

We have just mentioned a number of remedies which, when 
properly used, cause diminution and finally complete disap- 
pearance of the gonococci from the secretion, and more rapid 
recovery of the blenorrhoea, but the manner in which they act 
is not clear. 

I believe that the balsams have a direct parasiticide effect 
upon the gonococci rather than an action on the soil, for the 
reason that urine saturated with the drugs remains acid and 
sterile for a long time in open vessels, and is therefore a bad 
soil, at least for those micro-organisms which cause decom- 
position of the urine. 



Blenorrhcea of the Sexual Organs. 119 

In the application of astringent injections there is perhaps 
a double action, viz., destruction of the gonococci and an un- 
favorable modification of the soil, but only to the extent to 
which the cocci and soil are exposed to the action of the as- 
tringent. This superficial action may explain the fact that 
the cocci which rapidly penetrate deeply are only destroyed 
gradually, in the degree to which the suppuration again brings 
them to the surface, and thus the process lasts a long time. 

Treatment of Anterior Urethritis. 

We have previously referred to the expectant plan of treat- 
ment, which looks only to the most careful acquiescence in 
hygienic and dietetic measures, but avoids all local therapeutic 
interference. This method started with the followers of the 
avirulistic school. It cannot be denied that such measures, 
which include rest in bed, often suffice for the cure of blenor- 
rhcea, and I have very often observed, in hospital patients, 
recovery of an acute urethritis in a few weeks as the result of 
such treatment. But the period in which the blenorrhcea re- 
covers in such cases is usually quite long, dependent upon the 
soil, the rapid development of the gonococci, and the viability 
of the pus corpuscles. If the soil is changed as the result of 
previous blenorrhagic disease, i.e., after repeated infection, 
spontaneous recovery under expectant treatment is much 
more difficult of attainment. In the majority of patients, 
finally, it is impossible to carry out the hygienic-dietetic meas- 
ures in the strictness necessary to effect a cure. 

Next to this is the antiphlogistic method, which, starting 
from the theory of a simple inflammatory disease, recom- 
mended simple antiphlogistic regimen. Diuretics, leeches and 
venesections are employed, in addition to local applications of 
cold water. Although we do not favor the first-mentioned 
remedies, the local application of cold and warm water (the 
latter warmly extolled by Milton) is a very effective means, 
not of curing the blenorrhcea, but of keeping the inflammation 
within bounds, and preventing exacerbations as much as pos- 
sible. This is also true of the application of an ice-bag (Shane) 
or of the cooling apparatus with flowing cold water recom- 
mended by Bumstead and Otis. 

The topical application of cold water in the form of urethral 



120 BlenorrJicea of the Sexual Organs. 

injections was also recommended by Picard, while O'Reilly, 
Curtis, Gordon, and Blackwell strongly advised irrigations and 
injections of water as warm as could be borne. 

The medicinal, which is also chiefly a topical method of 
treatment has for its object to shorten the combat between 
the gonococci and mucous membrane, by attacking- the cocci 
and also by making the mucous membrane more resisting. 

It would be regarded as the ideal of medicinal treatment if 
we succeeded in preventing at once the further development 
of a beginning discharge from the urethra (whose blenorrha- 
gic character is shown by the presence of gonococci) by destroy- 
ing the gonococci, i.e., the virus, and thus removing the cause 
of the disease. This plan, known as abortive treatment, was 
formerly practiced a good deal. Musitanus (1701) injected a 
mixture of calomel, two drachms, and aqua plantaginis, eight 
ounces; Fordyce and Warren injected strong solutions of 
caustic potash. Simmons (1786) recommended cauterization 
with the solid stick of the entire urethra, Ratier of the fossa 
navicularis. But Debeney (1813) was one of the most active 
advocates of this method, which was practiced by the French 
school, particularly by Ricord. Solutions of nitrate of silver 
of various strengths were always emplo3~ed in these attempts 
at abortive treatment (0.7:30.0 by Carmichael, 0.5 to 1.0:30.0 
by Ricord, 0.6 to 1.5:30.0 by Debeney). This plan was carried 
out in the following way. The patient, who was kept in bed, 
first urinated. The physician then injected a syringeful of the 
solution into the urethra, at the same time compressing the 
penis at the root in order to prevent the deeper penetration of 
the fluid into the canal. After the solution had acted upon the 
mucous membrane (which is always accompanied by increas- 
ing violent pains), it is allowed to escape from the urethra and 
a syringeful of a one per cent, solution of sodium chloride is in- 
jected. The patient, who is placed on somewhat low diet, now 
applies cold compresses, and takes measures to secure easy 
evacuations. The first discharges of urine are followed by 
violent pains. On the next day begins a profuse, bloody, pur- 
ulent secretion, which gradually diminishes, and ceases almost 
entirely on the third day, when a fresh injection is made. 

In a certain proportion of cases (Tarnowsky estimates it 
at about 40 to 50 per cent.), the urethritis is cured in about 
two weeks under this treatment. In others the inflammatory 



Blenorrhoea of the Sexual Organs. 121 

symptoms become very violent after the injection, pain, chor- 
dee and vesical tenesmus set in as distressing- symptoms, and 
the continuance of the abortive plan is made impossible. Ber- 
ton and Yenot often observed other disagreeable complica- 
tions, such as peri-urethral abscesses, glandular inflamma- 
tions, epididymitis, as the result of abortive treatment; and 
Simon, who practiced this method in Germany, observed severe 
complications, such as prostatitis and cystitis, in four per cent, 
of the cases. Langlebert used his syringe " a jet recurrent," in 
order to confine the injection to any part of the canal desired. 
Chloride of zinc gr. f : § j., chloroform 1 :30, aqua calcis 1 :4, and 
alum 6 to 10:150 have also been recommended for abortive 
treatment. This was also attempted by the administration 
of large doses of copaiba and cubebs, but without striking 
benefit. The recent investigations on the rapid penetration of 
the gonococci into the deepest layers of the epithelium, and into 
the upper layers of the papillary body, offer no inducement 
for a return to the abortive plan of treatment. We could ex- 
pect success from those remedies alone which would destroy 
the entire epithelial layer and would penetrate to the papil- 
lary bodies. Hence the damage would be much greater than 
the good to be derived from certain destruction of the gono- 
cocci. 

In recent times Neisser (1889) recommends, as abortive 
treatment, the earliest possible injection of nitrate of silver 
(1 : 3000 to 1000) continued for a? long time. He states that this 
ameliorates the course and intensity of the acute symptoms 
and results in a positive cure. I will hereafter furnish the 
reasons for my opposition to topical treatment in the first, 
acute stage, and will here merely state that I have repeatedly 
employed this method but have never been able to continue it. 
Violent pains on injection and in micturition, oedema of the 
glans and prepuce, and sanguinolent secretion always com- 
pelled me to cease the injections after a few trials. 

Two other methods of abortive treatment have been re- 
cently recommended. 

Janet (1892) advises that the entire urethra be irrigated at 
once with a solution of permanganate of potash (1 : 2000). Five 
hours later the anterior urethra is irrigated with a solution 
1 : 1500, and five hours afterwards with a solution 1 : 1000. 
At the end of twelve hours another irrigation (1 : 2000) is per- 



122 Blenorrhoea of the Sexual Organs. 

formed, and this is continued every twelve hours for four to 
six days. The results are said to be a rapid disappearance of 
the gonococci and cessation of the secretion. Apart from the 
difficulty of carrying* out this plan of treatment, it is not ab- 
solutely reliable, from the few experiences which I have had, 
and does not prevent disagreeable accidents, such as increase 
of the inflammation, oedema of the glans, penis and prepuce, 
and irritation of the pars posterior. 

The second method, recommended by Koester (1890), and 
especially by Jadassohn (1892), consists in the injection of am- 
monium sulfo-ichthyolicum (one to five per cent.). This is not 
really an abortive measure. Although, as a rule, it rapidly 
produces considerable diminution of the gonococci in the secre- 
tion and of the amount of the latter, the rapid destruction of 
all the germs is not effected. A few gonococci remain, and 
rapidly increase after cessation of the injection, so that the 
treatment must be continued with other remedies. 

The failure of these "abortive methods" is a further proof 
of the rapid penetration of the gonococci into the depths of 
the tissues. 

The only method of treatment that we practice at the 
present time is the methodical, local, symptomatic and cura- 
tive plan. This plan, which is most generally adopted to-day, 
is unfortunately founded to too great an extent on an empir- 
ical basis, but we should combat the thoughtless and routine 
manner in which the method is tarried out. The consideration 
of the individual symptoms and the adaptation of the treat- 
ment to the requirements of the individual case alone can be 
followed by success. 

Symptomatic treatment, directed against individual symp- 
toms, is always indicated when the symptom in question re- 
quires repression. But is causal treatment always indicated, 
so long as the process is present ? We must answer this in the 
negative, and will mention a number of indications under which 
alone topical treatment is indicated. 

1. Causal topical treatment with balsams and astringents 
is only indicated in uncomplicated blenorrhcea. A series of 
extensions of the blenorrhagic process, such as cavernitis, 
cowperitis, prostatitis, epididymitis, cystitis, are produced by 
the spread of the inflammation from the diseased mucous 
membrane to adjacent organs. As soon as one of these com- 



Blenorrhoea of the Sexual Organs. 123 

plications develops, the topical treatment of the urethritis 
must be discontinued at once. In the first place a remission 
of the urethritis generally occurs on the development of the 
complication and makes its treatment temporarily superflu- 
ous. In the second place — and this is the most important 
reason and also holds good if the expected remission does not 
appear — every interference on our part during- the existence of 
a complication usually aggravates the latter. 

2. Early topical treatment, at a time when the disease is 
still increasing in intensity or is at the acme, is not indicated, 
and it should not be begun until the inflammation has passed 
the acme. 

We have previously discussed the action of balsams and 
astringents on the urethral mucous membrane and have said 
that, under their influence, the number of gonococci and the 
amount of the secretion diminish. It might therefore be sup- 
posed that they should be given at the very onset of the dis- 
ease, since it might be expected that the course of the disease 
would be made milder, that the inflammation would not rise 
so high. Whether this is so if injections are begun in the 
initial mucous stage, I do not know. Cases of this kind very 
rarely come under our observation, because the initial stage 
is so brief that it is generally overlooked by the patient. But 
if the purulent stage has set in, internal treatment should be 
employed with caution. If the inflammation is very acute, 
injections should not be ordered until the process has passed 
its acme. I know that I am at variance, in this matter, with 
some of my most prominent colleagues, who inject from the 
very beginning. But my conviction is founded not alone on 
an empirical but also on a scientific basis. I have never been 
able to convince myself that early injections shorten the proc- 
ess, but in some cases have observed direct injury from their 
use. After treatment of two groups of cases, in one of which 
I injected from the start, in the other after the cessation of 
the acute stage, I have become firmly convinced that in the 
former class the disease ran a milder course but lasted longer, 
and that leucocytes and gonococci (in scanty numbers) re- 
mained longer in the secretion than in the latter class. Zoege- 
Manteuffel (1892) reports that among 31 cases of blenorrhoea 
treated at once with injections complications developed in 25, 
and in only 4 cases among 24 which were not treated locally. 



124 Blenorrhcea of the Sexual Organs. 

These early injections have been employed mainly since the 
bacteriological era. In the eagerness to attack the germs the 
importance of the antiparasitic action is exaggerated, and an 
important factor, the vis medicatrix naturae, is overlooked. 
Inflammation and suppuration are effective weapons of de- 
fence, and should only be combated when we are able to re- 
place them with something better. Now the action of all 
remedies employed at the present time for injection is partly 
antiparasitic, partly astringent. The parasitic action is very 
incomplete, because in the urethra the germicide comes in con- 
tact with albuminoids (cells, serum) and coagulates them, and 
the effect of the drug is therefore lost in part. Furthermore, 
the germicide and gonococci do not come in sufficient contact 
with one another. Some of the gonococci are located in places 
(glands, connective tissue) to which the germicide does not 
gain access. 

Greater success attends the astringent action which we 
seek to obtain, but it is questionable whether we should so 
directly antagonize the vis medicatrix naturae, with its wea- 
pons the pus cells and pus serum. 

Another point must be considered. From Buram's inves- 
tigations on the development and spread of conjunctival blen- 
orrhcea, we know that the gonococci penetrate rapidly to the 
papillary body, where they proliferate. They are gradually car- 
ried by the current of the pus serum to the surface, and it is 
only during the latter part of the purulent and during the en- 
tire muco-purulent stage that they proliferate upon the epi- 
thelial surface. Accordingly, the proper period for antipara- 
sitic-astringent treatment would be the terminal stage. 

If we carefully follow the course of untreated blenorrhceas 
we will usualry be surprised by the rapid transition of the acute 
into the subacute stage. According to Bumui's description 
this is due to the final removal of the gonococci from the con- 
nective tissue of the sub-epithelium. One circumstance which 
favors this notion is the coincident appearance in the secretion 
of numerous epithelial clumps covered with patches of gono- 
cocci. 

I therefore repeat that I do not consider topical interfer- 
ence, especially injections, indicated until the blenorrhagic 
inflammation has passed its acme, and the cocci, which are 
then proliferating on the surface of the epithelium, are open 
to direct attack. 



Blenorrhcea of the Sexual Organs. 125 

3. The intensity of the topical interference must be inversely 
proportionate to the acuteness of the inflammation. The 
more severe the inflammation the milder the local measures, 
and vice versa. We therefore use the mild treatment with 
balsams before the injections, then inject weak solutions of 
the milder astringents, and finally stronger solutions in in- 
creasing concentration and frequency. It should not be for- 
gotten that suitable astringent action diminishes the intensity 
of the inflammation, a too strong action increases the intensity 
of the process, and thus gives rise to renewed invasion of the 
gonococci into the epithelium which has been fissured by the 
increased irritation. 

The method of administration of the balsams will be con- 
sidered in the discussion of the systematic treatment, but we 
will here make a few general remarks on injections. In acute 
anterior urethritis the injections are made by the patient with 
the clap syringe or my apparatus. 

The utmost cleanliness should be observed. The apparatus 
used for injections should be carefully cleaned in order that 
no germs which have developed in it can enter the urethra 
with the fluid. The solutions employed should also be aseptic, 
and vegetable injections must therefore be eschewed. Palliard 
reports a case in which a young man, get. nineteen years, in- 
jected an infusion of various herbs in recent urethritis. Three 
days after the first injection he was attacked by epididymitis 
and cystitis. The urine was cloudy and contained numerous 
bacteria, which the writer justly assumes to have been im- 
ported into the urethra with the injection. 

The mode of injection must be carefully described and shown 
to the patient. The solution must come in contact with the en- 
tire diseased mucous membrane, and must therefore penetrate 
to the bulb. This is only possible if the patient places the tip 
of the instrument in the meatus in such way that no fluid can 
escape. The fluid should be injected gently and uniformly. 
Violent, forced, rapid injection is apt to produce reflex contrac- 
tions of the ischio-cavernosi and bulbo-cavernosi muscles, which 
often eject the fluid from the urethra in the form of an ejacu- 
lation. 

The amount of fluid should always be so large that it will 
render possible a slight distention of the mucous membrane, 
an effacing of the folds, and entrance of the fluid into the 



126 BlenorrJicea of the Sexual Organs. 

openings of the follicles. The amount varies according- to the 
inflammation, but we may say that it should always he so 
large that the distention of the mucous membrane caused 
thereby begins to grow annoying or painful. In the beginning, 
so long as the membrane is very much swollen on account of 
the acute inflammation and its elasticity is slight, a small 
amount of fluid will produce painful distention. When the 
process becomes older, the amount of fluid mast be increased. 
These demands can be fulfilled very well with my apparatus. 
In the acute stage the patient uses it as an irrigator (without 
the piston) and allows the fluid to enter under slight pressure 
until the distention begins to grow painful, when he closes the 
stop-cock. When the process is older he allows larger amounts 
of fluid to enter under the gradually increasing pressure of 
weights placed on the disk of the piston, until the same effect 
is felt. 

The injected fluid must remain for some time in the urethra 
in order to act sufficiently upon it. 

It should always come in contact with the cleaned mucous 
membrane. The bladder should be evacuated and one or more 
injections of lukewarm water made before the fluid is intro- 
duced. 

At first the injections should be made only once a day, viz., 
at night, then the number may be increased to two, three, 
finally four. Too many injections irritate excessively. 

Having mentioned the general indications and recommen- 
dations we will now proceed to the consideration of the treat- 
ment of a typical case of acute anterior urethritis. 

If a patient with recent acute urethritis — say about the 
second week after coitus (more recent ones, as we have said, 
are rare) — comes under treatment, our first care should be to 
recommend strict hygienic-dietetic rules. One question, which 
we must often answer at once, concerns the amount of fluids 
to be drunk. Some recommend very little fluid, in order 
that the urethra may be irritated as little as possible by urina- 
tion, others recommend copious drinks, in order that the 
diluted urine should irritate the urethra only slightly. Both for- 
get that a single discharge of concentrated urine may irritate as 
much as the frequent passage of diluted urine, and that both ex- 
tremes should be avoided. In other respects we proceed symp- 
tomatically, combat sexual excitability with the well-known 



Blenorrhcea of the Sexual Organs, 127 

remedies, acute inflammatory phenomena with the application 
of cold compresses, which are employed for one or two hours 
morning' and evening". If the acute symptoms are very vio- 
lent, local treatment is contra-indicated. There are a few 
remedies which seem to alleviate the pain in micturition, for 
example : 

5 Decoct, semin lini., §xvj. 

Syr. diacodii, 3 hss. 

S. One tablespoonful every two hours. 

1£ Herb, herniar. 

Fol. uvae ursi, aa J 3. 

S. To he used as a tea. 

Two or three cupfuls of the latter mixture may be taken 
warm daily. Fournier recommends : 

^ Sodii bicarb., 3 j. gr xv. 

Sacch. alb., § j. 

Succi citri, gtt. ij. 

S. To be taken in one day. 

This is dissolved in about 1 litre of water and taken cold. 

If the inflammatory symptoms are slight, we may give local 
remedies even in this stage, prescribe a few capsules daily of 
oil of sandal wood or copaiba. These must be discontinued at 
once, however, if the irritative symptoms increase. 

Towards the end of the second week or beginning* of the 
third week the acute symptoms increase. The same regimen 
as before is continued, but more strictly. Rest, hygiene and 
diet must be very carefully watched. Antiphlogosis is useful 
only when carried out persistently. Employed for a time only, 
especially in the form of cold baths, it is injurious, inasmuch 
as the temporary relief is followed by a so much more violent 
reaction. The sexual irritability, the erections and insomnia, 
demand decided interference. We must not be afraid to se- 
cure the greatest possible amount of rest by suitable doses of 
the previously mentioned antaphrodisiacs, potassium bromide, 
camphor, lupulin, chloral hydrate, morphine injections, and at 
the same time order mild vegetable diet, and secure regular 
evacuations from the bowels. If the inflammatory symptoms 
are violent, as happens not infrequently at this time, we must 



128 Blenorrhcea of the Sexual Organs. 

enter the field with our entire antiphlogistic armament. Thus, 
oedema, lymphangioitis, chordee, require rest in bed, low diet, 
persistent application of cold compresses or ice bags, inunc- 
tions of gray ointment, and narcotics. In addition to mor- 
phine injections suppositories are especially suitable: 

3 Ext. belladonnas, gr. ij. 

or morphin. muriat., gr. ij. 

Butyr. cacao, 

Ungent. cinerit., aa 3 ij. 

F. supposit. No. x. 

S. Two to three suppositories daily. 

Next to chordee dysuria is particularly to be treated with 
narcotics. The catheter should never be used unless the in- 
dication is absolutely imperative. 

Protracted warm baths, if preceded by narcotics, often 
secure easy and relatively painless micturition in dysuria. 
In other cases dipping the penis in cold water is attended with 
good results. 

If the urethritis is not attended, even in this stage, with 
very severe inflammatory symptoms, and the administration 
of sandal-wood oil, etc., has been well tolerated, these drugs 
are to be continued. 

But injections should never be made until the inflammation 
has passed its acme. I have recently made an exception with 
regard to ammonium sulfo-ichthyolicum, which I inject from 
the beginning in not too acute cases. On account of its slight 
astringent action it is less contra-indicated than vigorous 
astringents. It rarely produces severe symptoms of irritation. 
The number of gonococci and the abundance of the suppura- 
tion are rapidly diminished, but the course of the disease is 
not shortened. It merely passes more rapidly into the sub- 
acute stage, which lasts so much longer. The remission of the 
symptoms is a signal for the administration of the balsams in 
those acute cases in which no local treatment has been hither- 
to adopted. 

We proceed to injections when the decreasing stage is well 
established. The pus, still abundant, loses its greenish tinge, 
becomes thin and milky. The pains on urination and erection 
are slight and rapidly diminish, the sexual irritability subsides. 
But it must not be forgotten that it is at this very time that 



Blenorrhcea of the Sexual Organs. 129 

posterior urethritis may develop. Before ordering- injections 
the physician must, therefore, satisfy himself concerning" the 
condition of the pars posterior, and repeat this examination 
frequently during* the further course of treatment. Not all 
injection fluids have the same value. We have already stated 
that the remedies and their strength must be increased. I 
can recommend the following practicable gradation: am- 
nion, sulfo-ichthyolic. (gr, xv.-l. : 3 iij.), potass, hypermang. 
(gr. J-f : 3 iij.), zinc, sulpho-carbolic. (gr. vi.-xij. : 3 iij.), argenti 
nitras (gr. j-iss: § iij.). These remedies are indicated so long 
as gonococci, pus corpuscles and clap shreds are still demon- 
strable. If these have been absent for some time we may 
order: sulphate of copper (gr. f-l|: 3 iij.), sulphate of copper 
with alum (gr. i.-vij. : f iij.), and especially subnitrate of bis- 
muth ( 3 ss.-i. : 3 iij.). 

The injection should never cause more than a slight burn- 
ing in the urethra. The urethra generally accommodates it- 
self very rapidly to the remedy. An injection which burns 
to-day will be felt very little or not at all in a few days. In 
the latter event its action may also be regarded as illusory. 
Hence it is advisable to increase the strength of the fluid every 
few days within the limits mentioned, and also to change the 
injection fluid. 

A very important question is, when is an acute urethritis 
to be regarded as cured, — when may the treatment be discon- 
tinued and the patient return to his ordinary habits of life ? 

Unfortunately mistakes are often made in practice by phy- 
sicians and patients, both in the direction of too brief and in- 
sufficient treatment, and also of excessively protracted treat- 
ment. 

Many patients are satisfied when the visible discharge of 
pus ceases. Unfortunately many physicians also discontinue 
the treatment when the patients inform them that the dis- 
charge has ceased. 

It is clear a priori that considerable amounts of pus still 
flow from the pars anterior. But if the amount of pus is small, 
it remains upon the mucous membrane of the urethra, spread 
out in a thin layer, and is only washed away by the urine dur- 
ing micturition. This occurs so much more readily because 
the small amount of pus of the terminal stage is mixed with 
considerable viscid, tough mucus, which favors its adhesion to 
the mucous membrane. This muco-pus is produced mainly in 



130 Blenorrhcca of the Sexual Organs, 

the bulb, inasmuch as the process, in typical acute anterior 
urethritis, passes from before backwards and halts in the third 
week at the bulb. Recovery also occurs in the same direction, 
so that in the fifth week the pendulous portion is healthy and 
the process is situated exclusively in the bulb. This is the 
time when no more secretion appears and many patients and 
physicians regard the process as cured. Thus urethritis of 
the bulb, while recovering", is most frequently disturbed in its 
normal course, and hence the most frequent localization of 
chronic urethritis in the pars anterior is found in the bulb. 

The premature cessation of treatment can only be avoided 
by examination of the urine. Inasmuch as the acid urine co- 
agulates the alkaline mucus, the small amount of pus will 
appear in the urine in the form of compact threads and flakes, 
the so-called clap threads; the urine is otherwise clear. So 
long as clap threads are found in the urine the process cannot 
be unreservedly regarded as cured. 

Not infrequently, on the other hand, the disease is treated 
for too long a period. After every urethritis a certain irrita- 
tive condition of the urethra remains, and is shown by increased 
secretion of clear, gelatinous mucus, as in urorrhoea. It is es- 
pecially in the morning, when the patient has been troubled 
by erections during the morning sleep, that the mucus appears 
in increased quantity, glues together the lips of the meatus, or 
appears as a clear drop on pressure. Many patients regard 
this condition as blenorrhoea. 

If this mucous secretion is left to itself, and care paid merely 
to the keeping away of external irritants, it will disappear 
spontaneously. But in the belief that it is a part of the ure- 
thritis the injections are continued. These constitute an irri- 
tant, however, and increase the secretion and irritative condi- 
tion of the mucous membrane which gives rise to it. It often 
happens that physician and patient become impatient, and 
resort to a more vigorous injection. This stimulates the des- 
quamation and proliferation of the epithelium, which, mixed 
with the mucus, gives the latter a gray or whitish color, which 
in turn seems to demand further injections. The patient thus 
enters a circulus vitiosus, the secretion becomes permanent, 
and if irritant bacterial immigration occurs as the result of un- 
cleanliness, the beginning is made of one of those forms which 
have hitherto been called chronic urethritis. 



BlenorrJioea of the Sexual Organs. 1 3 1 

The question of the duration of treatment can therefore 
not be answered by the secretion but only by examination of 
the clap shreds. There are two factors, in the main, which 
will prove decisive, viz., the pus corpuscles and the gonococci. 
So long* as the clap shreds contain gonococci, even if they are 
single, the treatment is to be continued. But even if the gono- 
cocci are missed in one or the other examination, the treatment 
is to be continued if the shreds are rich in pus cells. It hap- 
pens not infrequently that pus cells but no gonococci are found 
in the shreds for two or three days. On the fifth or sixth 
day a few cocci again appear. And so the presence of large 
numbers of pus corpuscles is evidence of the existence of an in- 
flammatory focus, whose cause may be attributed with great 
probability to the gonococci. But if the gonococci and pus 
corpuscles are both absent in the shreds, or the pus cells are 
present in very small numbers, while the majority of cellular 
elements are epithelial, the time for discontinuing treatment 
has arrived. The inflammation has then run its course and we 
have to deal merely with abundant desquamation of the .young 
epithelium, which will only be increased by injections. 

It is well to discontinue the injections gradually, not sud- 
denly, one injection being made at first every second day, then 
every third day, etc. 

After the injection cure is ended, the patient, adhering to 
the usual regimen, should be kept under observation for ten 
to fourteen days, and not until this period is past and the urine 
has remained clear, may we permit a gradual return to the 
ordinary mode of life. We must emphasize the advice that 
the return should be gradual, the patient indulging at first in 
the less dangerous privileges, and reserving coitus for the last. 

This is the symptomatic treatment of an acute, typical an- 
terior urethritis. In the most favorable event it requires a 
period of six weeks, a fact which it is well that the patient 
should be advised of beforehand. 

Not infrequently, however, subacute urethritides, which 
have lasted several months, come under our treatment. The 
delay is due to improper management, lack of treatment, pre- 
mature, improper, or interrupted treatment. In these cases 
we must inform ourselves concerning the presence of gono- 
cocci in the secretion and also concerning the cause of the de- 
layed recovery. When it is the result of insufficient care and im- 



132 Blenorrhcea of the Sexual Organs. 

proper regimen, these must be regulated; when treatment has 
been lacking-, rapid cure is usually effected. The most unfa- 
vorable cases are those which have been protracted by untimely 
and unsuitable treatment. In such cases I have made it a 
rule, and always with good results, to treat expectantly at 
first, merely regulating the regimen. If all local treatment 
is abandoned the blenorrhoea at first usually increases in se- 
verity, and usually passes a certain acme. This generally 
takes place within ten to fourteen days, during which period 
the patient is only treated symptomatically ; if the intensity 
of the process is not considerable, balsams may also be used 
but injections may not be employed. It is not until the proc- 
ess has passed its acme that I begin with systematic injec- 
tions, which secure rapid recovery, provided that no injurious 
influences are at work. 

Blenorrhoeas of cachectic, poorly nourished individuals, who 
are sick from other causes, deserve special attention. If they 
run a very acute course, they are treated in the ordinary way, 
except that tonic treatment is added, nourishing diet, iron, 
but particularly iron and arsenic in the shape of Roncegno 
water and Levico water. 

In these cases, however, the blenorrhoea often runs a tor- 
pid, mild course from the start, the inflammatory reaction is 
slight, the secretion thin and milky. Such a course indicates, 
from the beginning, tonic regimen, the well-known hygienic- 
dietetic measures, and cautiously conducted systematic injec- 
tions. The patient should always be prepared for a protracted 
illness and careful attention must be paid to posterior urethri- 
tis, which is apt to develop in a latent manner in these cases 
and to give rise to complications. In the event of such a 
complication the injections must be discontinued at once. 

Treatment of Acute Posterior Urethritis. 

Acute posterior urethritis is a complication of anterior 
urethritis which develops either at the acme of the inflam- 
matory process (in the third week), or subsequently from an ex- 
acerbation of the acute urethritis. 

On the development of and during the acute stage of this, 
as of all other complications, the main rule is the cessation of 
all treatment, particularly local, of the anterior urethritis. 



Blenorrhoea of the Sexual Organs. 133 

If the posterior urethritis has developed at the acme of the 
inflammation, no local treatment would have been adopted in 
any event. But if it develops later, from an exacerbation of 
the process, injections have already been ordered, perhaps, for 
the anterior urethritis. The local treatment must then be 
abandoned at once upon the development of the posterior 
urethritis. 

It is then our first task to treat the posterior urethritis, and 
to treat the anterior urethritis only after the former is cured. 

The posterior urethritis, on the other hand, may again give 
rise to a spread of the process, to the development of compli- 
cations. In this event the complication, for example, cys- 
titis or prostatitis, must first be treated, then the posterior 
urethritis and finally the anterior urethritis. 

The hygienic-dietetic measures are the same as in anterior 
urethritis. 

But I would caution the reader against the use of alkaline 
mineral waters. These waters diminish the acidity of the 
urine, a result which appears to me to be undesirable for two 
reasons. In the first place the acidity of the urine has already 
been diminished by the diet and rest, and in the second place 
alkaline pus (blood in cases of hematuria) will regurgitate 
into the bladder from the pars posterior. If the amount of 
these alkaline fluids, which enter the bladder, is abundant and 
the acidity of the urine has been considerably diminished by 
our medicinal treatment, this may constitute a cause for 
alcalescence and ammoniacal decomposition of the urine. 
The latter may be the immediate cause for the abundant pro- 
liferation of germs which have entered the bladder and thus 
for the production of cystitis. When posterior urethritis is 
present a sufficient degree of acidity of the urine is the best 
prophylactic against the spread of the inflammation to the 
bladder, against the production of cystitis. 

The general indications are also the same in both. The 
most acute stage is treated symptomatically, the diminishing 
but still acute inflammation is first treated with mild then 
with more vigorous local remedies, at first with balsams, then 
with injections. 

The symptomatic treatment of the acute stage is like that 
of anterior urethritis. Two factors demand special attention, 
viz., the hematuria and the disturbances of micturition. 



1 34 Blenorrhaea of the Sexual Organs. 

Hematuria is always an evidence of intense inflammation, 
and is associated with violent tenesmus; indeed it is usually 
caused by the latter. In some cases treatment of the tenes- 
mus suffices to relieve the hsematuria. The former demands 
our entire antiphlogistic armamentarium. In addition to rest, 
low diet and free evacuations, protracted lukewarm baths 
often render good service. But the greatest benefits are ob- 
tained from narcotics. Injections of morphine and supposi- 
tories of belladonna always relieve the tenesmus, and also the 
inflammation, inasmuch as the latter is intensified by the for- 
mer. The previously mentioned decoctions, either with or 
without narcotics, such as infus. semin. lini, herniaria, folia 
uvae ursi, also cause some amelioration and are indicated in 
the acute stage. 

If the hemorrhage in the last drops of urine does not cease 
with the tenesmus, the former must be treated alone with 
haemostatics, especially iron and ergo tin. We prescribe : 

fy Ferri sesquichlor. sol., 3 ss. 

Aq. destil., I vj. 

Syr. cinnamon, 3 v. 

S. One tablespoonful every two hours. 

5 Ext. secal. cornut., .... 

Sacch. alb., 

Mf. pulv. div. in dos. v. 

S. One powder every three hours. 

^ Ergotini, 

Opii, 

Sacch. alb., 

Mf. pulv. div. in dos. v. 

S. One powder every three hours. 

Granules of Bonjean's ergotin or subcutaneous injections 
of ergotin are also given with advantage. 

Dysuria, which is not infrequent in acute posterior urethri- 
tis, is also a spasmodic symptom, and therefore to be treated, 
in the main, by morphine and belladonna. The introduction 
of the catheter is to be avoided or reserved for the most urgent 
cases. A narrow elastic catheter may then be used during 
chloroform narcosis or after the administration of morphine 
(subcutaneously or in suppositories). 



gr. 


XV. 


gr. 


XXX. 


gr. 


XV. 


gr. 


iss. 


gr. 


XXX. 



Blenorrhoea of the Sexual Organs. 135 

When the irritative symptoms have disappeared, in the 
main, and albuminuria is not present, we may proceed (in ad- 
dition to the continuance of mild narcotic treatment by ad- 
ministration of two belladonna suppositories or infus. semin. 
lini with syrup, diacodii) to cautious local treatment. We 
may give a few (4 to 6) capsules of sandal-wood oil or copaiba, 
but these must be discontinued at once if more marked irri- 
tative symptoms, particularly increased tenesmus, become 
noticeable. 

If the patient does not tolerate the balsams, we may give, 
instead of or in addition to them, salicylate of soda in doses 
of gr. xxx. three times a day. 

When all irritative symptoms have disappeared for several 
days, especially if there is no severe tenesmus or albuminuria, 
and if the cloudiness of both portions of urine is decidedly 
lessened, we may proceed to local treatment with astringents. 

We have previously stated that astringents, injected with 
the ordinary clap syringe, do not enter the pars posterior, and 
hence this method of injecting is to be avoided in the treat- 
ment of posterior urethritis. 

The French recommend, in order to carry the fluid by means 
of the clap syringe into the pars posterior, to close the meatus 
and to push backwards the fluid in the urethra by means of 
pressure. This manipulation succeeds in some cases. The 
patient then finds that the pendulous portion, which was at first 
tense, becomes more flabby, and when the meatus is released, 
very little fluid escapes from it. In other cases, however, the 
fluid as soon as it reaches the compressor is ejected from the 
urethra by reflex, jerky contractions of the bulbo-cavernosi 
and ischio-cavernosi muscles. 

This method is uncertain, and is always irritating even in 
the event of success. We deprecate it accordingly, and with 
Ultzmann, Aubert, Eraud, maintain that posterior urethritis 
should always be treated by the physician by direct local ap- 
plication of the remedy to the pars posterior. 

It must not be forgotten that when the acute posterior 
urethritis is at a period suitable for injections, an anterior 
urethritis is also present, older and less severe than the former, 
and also suited to treatment with injections. 

It will be our object, in all these cases, to secure contact of 
the astringent solution with the entire urethra, from the ex- 
ternal to the vesical orifice. 



136 



Blenorrhoea of the Sexual Organs. 



The patient should never make the injections in posterior 
urethritis with the clap syringe. The anterior urethritis may 
be healed in this way, but the posterior urethritis, if not ag- 
gravated, is at least left to run its spontaneous course, which 
usually terminates in chronicity of the process. The best 
method of injection is that of Diday, or the use of Ultzmann's 
irrigation catheter, with distribution of the fluid over the en- 
tire urethra. In order to make the entrance of the solution 
into the bladder entirely innocuous it is advisable to make the 
injections when the bladder is moderately full. The removal 
of the fluid from the bladder is unnecessary. The solutions 
are to be lukewarm, and 3 vij.-x. in amount, of which some- 
what less than half is intended for the pars posterior, the re- 
mainder for the pars anterior. The urethra must be clean 
before introduction of the instrument, and the patient should 
therefore evacuate some, but not all, the urine in the bladder 
immediately before injection. In sensitive individuals a mor- 
phine suppository may be introduced before the first injections 
in order to avoid disturbing reflex contractions of the com- 
pressor. The injections should be made, at first every third, 
later every second day. 

The following fluids may be prescribed : 



^ Ammon. sulfo-ichthyolic, 
Aq. destil., 

5 Acid carbolic, 
Aq. destil., 

fy Potass, hypermang., 
Aq. destil., 

^ Argent, nitrat., 
Aq. destil., 



3 iiss. 
I xvi. 

gr. xv. 

3 xv. 

gr. iij.-viiss. 
3 xv. 

gr. iij.-xv. 

ixv. 



Some employ injections in posterior urethritis by injecting 
the remedy through a catheter into the empty bladder and 
then allowing the patient to urinate. We do not consider 
this plan advisable. In the first place, it is well to avoid irri- 
tation of the walls of the bladder by the astringent, and in the 
second place, even " an empty bladder " contains sufficient 
urine to decompose the astringent in part or entirely. We 
also object to irrigation of the posterior urethra without a 
catheter by simple high pressure. Irrigations with a catheter 



Blenorrhcea of the Sexual Organs. 137 

are undoubtedly the mildest method of injection and the most 
certain to prevent disagreeable accidents. 

If the subjective symptoms have disappeared and the ob- 
jective signs consist merely of slight mucous cloudiness of both 
portions of urine, we may advantageously employ the solutions 
recommended for acute anterior urethritis, particularly argenti 
nitrat. 0.1 to 0.2: 100.0. In these cases " anthrophores " may 
also be used to advantage. 

Acute posterior urethritis usually heals more rapidly than 
the anterior, so that we generally find, after the treatment 
has been continued for some time, that the second morning 
urine is entirely clear while the first is still slightly cloudy, i.e., 
the posterior urethritis is cured, the anterior urethritis still 
present. Irrigations are then unnecessary; the anterior ure- 
thritis is to be treated with the clap syringe, and the treat- 
ment then discontinued in the manner described above 



OHAPTEE III. 

CHRONIC URETHRITIS. 

Etiology. 

Chronic clap was recognized at a later period than the 
acute form, and although urethral stricture and its treatment 
by dilatation were known since the middle of the sixteenth 
century, the course and characteristics of the preceding- chronic 
urethritis were not closely studied until the beginning of the 
present century. Girtanner (1788) characterizes chronic clap 
as: stillicidium muci puriformis vel limpidi ex urethra vix in- 
flammata, sine stranguria, erectiones non dolorificse, ab ulcere 
urethrse, aut a coarctatione praeternaturali urethras. Kuehn 
(1785) defines chronic clap as a discharge of moisture which is 
left over after a clap, and results from the weakness of the 
parts which have been affected. Eisenmann(1830) applies the 
term chronic to every case which lasts more than twenty-one 
days. 

We have said that acute urethritis passes through a muco- 
purulent and mucous terminal stage before recovery ensues. 
This stage may become permanent, and it is to this protracted 
symptom-complex of the terminal stage of acute blenorrhoea 
that we apply the term chronic blenorrhoea. 

This determines the etiology of chronic blenorrhoea in the 
widest sense. Every chronic urethritis develops as the sequel 
of an acute or subacute urethritis, whether anterior or pos- 
terior. 

When the mucous or muco-purulent stage becomes perma- 
nent it usually becomes localized. The diffuse inflammatory 
process, which constitutes acute urethritis, persists in more or 
less circumscribed spots and recovers in the remainder of the 
mucous membrane. The causes of this localization reside in 
the anatomical conditions, the greater abundance of follicles 
and glands, and the consequent increased vascularization. 



Blenorrhcea of the Sexual Organs. 139 

The anatomical investigations in Prof. Weichselbaum's In- 
stitute give the following results. 

The foci of chronic urethritis were found in : 

Pars pendula alone, in 15 cases 

Pars pendula and bulb, " 1 case 

Bulb alone, " 1 « 

Pars pendula and pars prostatica, . . . " 1 " 

Pars pendula, bulb, and pars prostatica, . . " 5 cases 

Pars membranacea and pars prostatica, . . " 1 case 
Pars pendula, bulb, pars membranacea, and pars 

prostatica, . . . . . . " 1 " 

Pars prostatica alone, "6 cases 

31 cases 

We will therefore define chronic blenorrhcea as the perma- 
nency of the mucous terminal stage of acute urethritis in a 
circumscribed portion of the urethra, with recovery in other 
parts. Its favorite sites are the bulbous, membranous and 
prostatic portions. 

Its causes are in part neglect of the acute blenorrhcea in 
the sense of insufficient treatment, in part and more fre- 
quently, recurring' relapses as the result of external injurious 
influences, and finally, rapidly recurring fresh infections. 

We have already discussed the drawbacks of insufficient 
treatment. The diagnosis of recovery is often made prema- 
turely because suppuration has ceased, while complete recov- 
ery has not occurred ; but the process, which is confined to the 
bulb, produces too little pus to appear in the form of a dis- 
charge. And so the disease in the bulb remains untreated and 
becomes chronic. 

In the same way the localization of acute urethritis is usu- 
ally made very loosely or not at all, and the treatment only 
carried on with the syringe. 

Now, if a mild posterior urethritis was present in addition 
to the anterior urethritis, the former is apt to be overlooked 
and alone remains chronic. To the insufficient or improperly 
localized treatment, are usually added other active injurious 
factors. The patient, either on his own responsibility or that 
of his physician, regards himself as cured and lives accord- 
ingly. This is usually attended with so much more serious 



140 Blenorrhcea of the Sexual Organs. 

results to the not entirety healed process, because the patient 
believes that he should make up for the hardships of the period 
of treatment. Then comes a relapse, which is treated aud 
disappears. Then follows another relapse on account of pre- 
mature return to the usual mode of life. Thus relapse follows 
relapse, each succeeding' one less pronounced and shorter, but 
with each one the process becomes more and more firmly 
seated, the local changes deeper and more serious. 

The same condition is observed in fresh infections if these 
follow one another rapidly. Their acuteness successively di- 
minishes, they grow more torpid and subacute, but each be- 
comes more obstinate. The long" duration alone predestines 
the transition to chronic blenorrhcea, because its mild course 
does not convince the patient of the necessity of thorough 
treatment, proper hygiene and diet. 

One question must be here considered, viz., the question of 
the possibility of repeated gonorrheal infections. Formerly 
this question was answered unhesitatingly in the affirmative, 
and reports of various new infections within a brief period 
were reported and believed. At the present time, however, 
we are more skeptical in regard to such reports. This skepti- 
cism is due to the obstinacy with which the grmococcus main- 
tains its hold and to the fact that the recovery of the blenor- 
rhcea is often assumed prematurely by the patient and the 
physician. 

The following" remarks may be made in this connection: 

In the first place blenorrhcea, after its complete cure, fur- 
nishes absolutely no immunit}'. I have observed numerous 
perfectly reliable cases in which the patients were reinfected 
with a fresh blenorrhcea in one to three months after undoubted 
cure of an acute blenorrhcea. 

Furthermore, the existence of a chronic blenorrhcea,whether 
it contains gonococci or not, is absolutely no hindrance to re- 
newed infection. I have sufficient clinical evidence on this 
point, and at the same time Ghon and I have investigated it 
experimentally. In four patients suffering from chronic blen- 
orrhcea, two with g-onococci, two without the germs, we inoc- 
ulated pure cultures of gonococci. At the end of forty-eight 
hours' incubation, in all four cases, a typical acute blenorrhcea 
developed with abundant gonococci, which were again demon- 
strated by cultures. The influence of this acute blenorrhcea 
upon the original chronic process was always beneficial. 



Blenorrhoea of the Sexual Organs. 141 

Fresh infections are always distinguished from relapses by 
the fact that the relapses beg-in at once, the fresh infection 
only two or three days after coitus, i.e., after a period of incu- 
bation. 

There are also certain factors within the organism which 
favor the development of chronic blenorrhoea. 

We have already said that torpid subacute blenorrhceas 
have a special tendency to pass into the chronic stage. On 
the other hand we know, from the symptomatology of acute 
urethritis, that this is more apt to run a torpid subacute course 
in cachectic, scrofulous and phthisical individuals. 

Finally, the transition of many blenorrhceas into a chronic 
stage is attributed to a narrow meatus, to the stasis and re- 
gurgitation of the stream of urine which passes through the 
entire urethra in a broader column. 

Nevertheless the real etiological factor of chronic, as of 
acute urethritis, is the gonococcus, which has a fixed settle- 
ment on circumscribed portions of the urethra. This will be 
considered more fully in the sections on symptomatology and 
anatomy. To one fact I wish to call attention here, viz., that 
the gonococci usually suffer enfeeblement during their long 
protracted stay on the mucous membrane. It has, at least, 
been claimed by several writers (Noeggerath, Milton, Schwartz) 
that women are infected, by their husbands, who suffer from 
chronic gonorrhoea, with urethritis which runs a chronic course, 
and very rarely with acute blenorrhoea. 

Symptomatology. 

The symptomatology of chronic urethritis is usually de- 
scribed as the escape of a yellowish or whitish drop from the 
urethra, and gluing together of the meatus, without subject- 
ive phenomena; these symptoms maybe aggravated by ex- 
ternal injurious influences. 

This clinical history is inaccurate and corresponds to only 
a single form of chronic urethritis. All the different varieties 
cannot be brought under one head, and require special con- 
sideration. 

The symptoms and course vary not alone according to 
the localization, but also according to the depth to which the 
circumscribed inflammatory process has extended. In some 



142 Blenorrhcea of the Sexual Organs. 

cases it affects only the mucous membrane, in others also the 
submucous cellular tissue and other subjacent tissues. 

From this stand-point we may distinguish several forms, 
which can all be arranged in two groups. 

We have said that one of the characteristics of chronic 
blenorrhoea is its circumscribed localization. But if we include 
in the category of chronic blenorrhcea only those cases in 
which the process is really confined to a quite sharply defined 
spot, we would have to exclude a series of cases, because, al- 
though they present a torpid course and absence of acute in- 
flammatory symptoms, congestive phenomena are also ob- 
served on larger or smaller portions of the mucous membrane. 
These are the transitional forms between acute and really cir- 
cumscribed chronic urethritis. 

The differentiation between these two forms, which I will 
call recent and inveterate chronic blenorrhcea, depends on the 
character and quantity of the secretion. If the urine, espe- 
cially the morning urine, is examined in a large series of cases of 
chronic urethritis, the characteristic clap threads will usually 
be found. These shreds are the product of the circumscribed 
process which constitutes the chronic urethritis. In the one 
series of cases the shreds are found floating in cloudy urine, 
in the other in clear urine. 

The cloudiness in the more recent cases of chronic urethri- 
tis is caused by mucus, and is owing to the fact that, in addi- 
tion to the circumscribed patches which produce the shreds, 
there are more or less extensive parts of the mucous mem- 
brane in a condition of catarrhal hypersecretion, while the 
clear urine in the second series of inveterate chronic urethritis 
indicates that the remaining mucous membrane is normal. 
If an inveterate chronic urethritis is irritated by external 
influences, the symptomatology of the more recent form is 
not infrequently produced, but disappears after a longer or 
shorter interval. In like manner, the clinical history of 
the more recent form passes, in time, into that of the invet- 
erate form. 

Several forms of chronic urethritis may be differentiated 
according to the localization. 



Blenorrhcea of the Sexual Organs. 143 

I.— Chronic Anterior Urethritis. 

This furnishes the picture of the usually described typical 
goutte militaire. When the patient examines the penis in the 
morning, he finds a drop emerging* from the meatus, yellowish 
or milky in the more recent cases, grayish white in older ones; 
in the latter event it not infrequently contains whitish little 
clumps. The morning urine, which is passed without pain, or, 
at the most, with slight burning and tickling at the orifice, is 
clear or cloudy and contains shreds. If the patient urinates in 
two vessels, that passed first alone is flocculent, and clear or 
cloudy, the second is always entirely clear. During the day the 
meatus is usually glued together by a small amount of mucus; 
the first usually clear urine contains flakes, but in smaller 
amount than in the morning. If the process is more recent and 
the mucous membrane hypersemic, the mucus is stained more 
or less yellow by the larger or smaller amount of pus produced 
by the mucous membrane which is in a condition of chronic 
infiltration. This mucus escapes in the morning as a drop at 
the meatus, while that produced during the day, being smaller 
in quantity because washed away at shorter intervals by the 
urine, merely agglutinates the meatus. In the older cases 
the pus from the diseased portions of the mucous membrane is 
washed away by the first urine, and hence cloudiness of the 
second urine is impossible in both cases. Exacerbations of this 
chronic condition as the result of external irritants are so 
much more easily recognized. 

Chronic urethritis, which is localized in the pendulous por- 
tion, has such distinct symptoms because the slight amount of 
secretion always gravitates toward the meatus. If the pus 
is formed in the bulb in small quantities it will remain there, 
and only appears in the first urine as clap threads, but does 
not flow out of the meatus nor is it visible as a drop. If the 
chronic urethritis is more recent, and the congestion and pro- 
duction of mucus upon large portions of the mucous membrane 
of the pars pendula are more extensive, the mucus may reach 
the meatus and agglutinate it. But if the urethritis is old, 
this mucus at the orifice is absent, the process is only notice- 
able by the clap shreds. The patient, in the absence of all 
symptoms, naturally regards himself as well. Slight exacer- 



144 Blenorrhoea of the Sexual Organs. 

bations, such as burning during micturition, are explained by 
the new beer which the patient drank on the previous even- 
ing-, and more severe relapses are regarded and treated as 
mild, new infections. 

So long as the process remains localized in the mucous 
membrane, these are the symptoms which may persist for 
years. That such a chronic urethritis, situated solely in the 
mucous membrane, may heal as the result of recovery of the 
spot of infiltration by the formation of connective tissue and 
superficial cicatrices, I have proven by post-mortem examina- 
tion. When the process extends to the submucous tissue, to 
the corpus cavernosum, and the chronic infiltration heals by 
the formation of retracting connective tissue, a new and 
gradually developing symptom of more serious significance 
is added to the clinical history, viz., narrowing or stricture. 
Apart from spasm urethral strictures also arise from organic 
causes, from swelling or infiltration of the mucous membrane, 
-or the formation of cicatrices. The former, known as soft 
strictures, are succulent, yielding, rarely attain a notable 
degree, indeed the stenosis is usually insufficient to narrow 
the pars pendula and bulbosa to the dimensions of the orifice. 
They cannot be detected, as a general thing, with the ordinary 
sound, but only with sounds of large calibre or urethrometers. 
Otis calls them "wide strictures." On the other hand, the 
strictures formed by retracting tissue have a tendency to 
constantly increasing narrowing. They are situated mainly 
in the bulb and its vicinity. Of 320 strictures, whose locality 
was examined by Thompson, there were situated : 

1. At the orifice of the urethra and within two and a half 
inches of the pars pendula, 54=17 per cent. 

2. At the middle of the pars spongiosa, two and a half to 
five and a half inches from the orifice, 51 = 16 per cent. 

3. In the subpubic curvature, i.e., the bulb and beginning 
of the membranous portion, 216=67 per cent. 

The strictures always develop very slowly. Thus, Thomp- 
son gives the period of development among 164 cases in 

10 cases during the acute blenorrhoea. 

71 " 1 year. 

41 " 3 to 4 years. 

22 " 7 to 8 " 

20 " 20 to 25 " after the termination of the urethritis. 



Blenorrhcea of the Sexual Organs. 145 

This affection, which belongs to the field of surges has 
been the subject of such excellent, in part monographic, trea- 
tises that we will not consider it here. 



II.— Chronic Posterior Urethritis. 

Like the preceding form this runs a latent course in many 
cases. The clap shreds, which are produced only in the in- 
veterate cases, remain deposited in the pars prostatica, and 
are discharged during micturition with the first urine. Never- 
theless prostatic urethritis presents some variations in symp- 
tomatology which not infrequently permit us to ascertain its 
situation. This is true of the more recent form, with produc- 
tion of mucous secretion in addition to the clap shreds. If 
this mucous secretion is produced abundantly, as happens not 
infrequently during the night, it is discharged into the blad- 
der, especially when the latter is considerably distended, and 
then causes cloudiness of the second urine. The diagnosis of 
chronic posterior urethritis is therefore favored by cloudiness 
(usually of a slight grade, which makes the impression as if 
the glass vessel, into which the urine was passed, is " sweat- 
ing ") of both portions of the morning urine, in addition to floc- 
culi in the first urine. Another circumstance must be taken 
into consideration. The mucous membrane of the pars pros- 
tatica is rich in glands, which are enclosed in the prostate, and 
empty on both sides of the caput gallinaginis. The inflam- 
mation generally extends to the excretory ducts of these 
glands, and they become occluded by a plug of mucus, pus and 
epithelium, which has the appearance of a comma. Unlike 
the clap shreds, which are deposited on the mucous mem- 
brane, these quite firmly adherent plugs are not washed away 
by the first stream of urine. They are expressed by the con- 
traction of the compressor muscles, which shut off the bladder 
and squeeze out the last drops of urine from the pars poste- 
rior, and they are therefore found in the second urine. A 
second, slightly mucous, cloudy urine, or the presence of hook- 
shaped and comma-shaped clap shreds in the second cloudy or 
clear urine, testifies in favor of chronic prostatic urethritis. If 
it is confined to the mucous membrane, it usually presents no 
subjective symptoms. 

The process is essentially different and much more serious 
10 



146 Blenorrhoea of the Sexual Organs. 

when the inflammation extends deeply, beyond the mucous 
membrane. In the pars prostatica the mucous membrane 
passes over the prostate, an extremely complex organ, which 
is very rich in nerves and glands, is intimately related to 
the sexual organs, in its developmental history is analogous, 
in a certain sense, to the female uterus, but belongs to the 
uropoetic system on account of its muscular tissue. Exten- 
sion of the chronic inflammation, at first to the caput gallin- 
aginis and the glands of the prostate, then to the prostate 
itself, produces a severe form of chronic urethritis. Irritative 
symptoms of various kinds set in, and affect the secretion of 
urine as well as the sexual sphere and nervous s}^stem. 

Tenesmus occurs as a disturbance of urinary secretion. In 
some cases this is manifested merely by somewhat more fre- 
quent desire to urinate; the patients simply imagine that the 
capacity of the bladder has diminished. 

In other cases the feeling of increased desire to urinate is 
provoked by other functions, especially defecation and coitus. 
After each defecation, especially if the passage of firm fecal 
masses has exercised strong pressure on the prostate, the 
patients experience a more or less violent desire to urinate, 
which cannot be satisfied, inasmuch as the bladder was emp- 
tied during defecation. This desire lasts until urine has again 
collected in the bladder and has been discharged, whereupon 
it ceases at once. In other cases the patients are compelled 
to urinate two or three times at short intervals before the 
tenesmus ceases. It may be produced by examination per 
rectum and pressure above or upon the prostate. 

In some patients annoj'ing, but not violent, tenesmus oc- 
curs after coitus or pollutions, but ceases after the patient has 
micturated one or more times at short intervals. 

In addition, there are usually irritative symptoms in the 
sexual sphere. The patients often complain that the feeling 
of pleasure during coition is lost. Or they complain of a more 
or less violent darting pain in the back part of the urethra or 
the rectum, which occurs at the moment of ejaculation and 
drowns the feeling of pleasure. The form of impotence known 
as irritable weakness, is also very frequent. The patients have 
g*ood erections and the sexual excitement is present, but this 
causes premature discharge of semen, which occurs before 
immissio or immediately after the beginning of coitus. The 



Blenorrhcea of the Sexual Organs. 147 

erection then subsides at once and a long time elapses before 
a new one develops. Pollutions are also a frequent complaint 
of the patients, who experience a coincident diminution of 
potency. 

These patients are very often frightened by another cir- 
cumstance. They often tell us that they suffer from an escape 
of semen. On closer inquiry it is learned that w^ith each defe- 
cation, especially if difficult, the patients notice the escape of 
a cloudy, thickish, mucous fluid which they regard as semen. 
Pressure on the prostate through the rectum discharges the 
same secretion, which is shown by microscopical examination 
to be the product of the prostate in a condition of catarrhal 
inflammation (prostatorrhoea) 

Other patients really suffer from spermatorrhoea, but it 
usually remains latent. Not very infrequently a few sperma- 
tozoa can be found in the urine of patients suffering from 
chronic urethritis. They are found occasionally in prostator- 
rhoea, but their number is small. In other cases semen is dis- 
charged in abundance during micturition and defecation — mic- 
turition and defecation spermatorrhoea. Fuerbringer regards 
this as the result of evacuation of the seminal vesicles by press- 
ure, the ejaculator3 T ducts being relaxed at the same time by 
the chronic blenorrhcea. In a case of profuse defecation-sper- 
matorrhoea from chronic urethritis in a man of thirty years, 
I observed the discharge of exclusively motionless sperma- 
tozoa, in addition to impotence and complete absence of erec- 
tions. 

Fuerbringer (1886) showed that the spermatozoa in the semi- 
nal vesicles are motionless, and that it is only the entrance of 
the normal prostatic fluid which awakens their latent vitality 
and makes them capable of movement. This explains my 
observation of motionless spermatozoa in defecation-sperma- 
torrhoea, inasmuch as the semen evacuated in this way is 
probably not mixed with prostatic secretion. Fuerbringer 
has reported similar observations. The prostatorrhoea just 
mentioned also merits attention from another point of view. 
The normal prostatic secretion is acid. Mixture with alkaline 
pus may make this reaction neutral or even alkaline. Will 
the prostatic secretion, when changed in this way, also vitalize 
the spermatozoa ? In this way a simple posterior urethritis 
may give rise not alone to impotentia coeundi, but also to 
impotentia generandi. 



148 Blenorrhcea of the Sexual Organs. 

With the implication of the caput gallinaginis, an organ 
extremely rich in nerves, is produced a series of morbid nerv- 
ous phenomena, which are manifested by increased irritability 
and exhaustibility of the nerves, and is known as sexual neu- 
rasthenia. 

The functional sexual disturbances which we have already 
mentioned also belong* to the domain of neurasthenia. In ad- 
dition there is an entire series of nervous disturbances which 
are partly localized, partly of a spinal nature, and in part are 
manifested by general nervousness and neurasthenia. The 
local nervous disturbances include l^yperesthesiae, paresthesias 
and paralgiae in the urethra. During micturition the patient 
experiences a feeling of heat or burning in the urethra, which 
makes him think of an inflammatory process in the canal, or 
sometimes pains and darts in the urethra appear spontane- 
ously. Many patients complain particularly of a dull painful 
feeling, as if the penis were constricted in the region of the 
urethra. The hyperesthesia is not infrequently so great as to 
produce reflex spasms of the compressors. The urine is then 
ejaculated by jerks in a thin stream, and gives rise to the 
notion of a stricture. Introduction of a sound into the urethra 
produces spasmodic contractions, especially of the compressors. 
The painful sensations also radiate into the distribution of the 
plexus sexualis, along the spermatic cord and into the testicles 
(partly as dull pressure, partly as lancinating pains), and also 
into the perineum and the anal opening. The latter in partic- 
ular is not infrequently the site of hyperesthesia and reflex 
spasms. The latter are often so violent that digital examina- 
tion per anum becomes impossible. In other cases the anus is 
the site of an intolerable pruritus which is either continuous 
or paroxysmal. The scratching induced by the pruritus gives 
rise to eczema. Frequent eruptions of herpes on the glans, 
prepuce and integument of the penis also annoy the patient. 
These develop spontaneously or follow sexual excitement, 
coitus or pollutions. The general condition always remains 
good, the appearance and nutrition may be excellent. Never- 
theless the patients are usually in a deplorable state. The 
impotence and pollutions depress the mind, the various sensa- 
tions rouse the belief in some serious disease which is concealed 
by the physician, the mood is gloomy and hypochondriacal. 
This is especially true when the nervous disturbances spread 



* Blenorrhcea of the Sexual Organs. 1 49 

farther, and other spinal symptoms are added. These include 
the various manifestations of spinal irritation, pressure and 
pain in the back, formication, cold or heat along- the spine, 
radiating neuralgias and paralgias, particularly in the lumbo- 
sacral plexus. The neurasthenic symptoms may also spread 
farther. Digestion then suffers, symptoms of gastric and 
intestinal catarrh set in, but are only the result of atony. 
These reduce the patient, and his condition is thus aggravated 
materially. The nervous symptoms become more severe. 
There is general depression, pressure in the head, mental ob- 
tuseness, palpitation of the heart, etc. The unstable vasomotor 
system causes rapidly changing color, pallor and redness, es- 
pecially in the face. Digestion is poor, the local symptoms 
in the domain of the uropoetic and sexual organs attain con- 
siderable intensity — no wonder that not a few of these patients 
terminate their existence by suicide. 

Secretion. 

We have already described the various forms under which 
the inflammatory secretion appears in chronic urethritis. This 
secretion may appear in the form of a drop, or it is so slight 
or is produced so deep in the urethra, that it cannot escape, 
and is then found in the urine in the shape of shreds. 

If it escapes from the urethra as a drop, its microscopical 
appearances are like those of the pus in the terminal stage of 
acute urethritis. We then find multi-nuclear pus cells, either 
singly or arranged in small groups, and various transition 
forms of epithelium, round, polygonal, spindle-shaped and cau- 
date cells with a large nucleus. In addition large uni-nuclear 
flat epithelium and cylindrical epithelium cells are not infre- 
quent. 

These cellular elements, agglutinated by finely granular 
mucin, are found more frequently in the urine (Plate III., .Fig. 
8) as clap threads than in the form of drops. Macroscopically 
we may distinguish two varieties or extremes of these clap 
shreds. They may be narrow, mucous, delicate and trans- 
parent, often very long and branched shreds, which consist of 
a good deal of mucus and few cellular elements, or they are 
shorter, firmer, whitish threads, in which the cellular elements 
predominate. The proportion of epithelial and pus cells varies. 



150 Blenorrhoea of the Sexual Organs. 

In the first-mentioned form the epithelium predominates, in 
the latter the pus cells. Mucous threads with much epithelium 
are a more favorable prognostic sign than short shreds with 
much pus. 

The shape of the shreds varies, but does not permit any 
conclusion with regard to the situation or intensity of the proc- 
ess. Produced upon the diseased mucous membrane and ad- 
herent to it, they are separated by the stream of urine and 
carried away. In addition we find not infrequently short, 
comma-like, punctate, usually firm flocculi. These come from 
the excretory ducts of the various glands and follicles, and, 
when present in large numbers, are significant of a more in- 
tense implication of the urethral glands and therefore of a 
severe process. As we have previously remarked, these comma- 
like shreds, which are found in the second portion of the urine 
and are formed in the glands of the prostate, are signs of 
chronic prostatic urethritis. Their structure is usually char- 
acteristic. They are composed of two superimposed layers of 
cylindrical cells. The upper layer, consisting of large cells, 
sends processes into a mosaic of small, almost round epithe- 
lium cells (Fuerbringer, 1883). 

The microscopical appearances of prostatorrhcea are essen- 
tially different. Aside from the negative condition of absence 
of spermatozoa or their presence in small numbers, we find 
in the prostatic secretion (Fig. 19) numerous pus cells, polyg- 
onal and cylindrical epithelium, more rarely the double layer 
of cylindrical epithelium of the excretory ducts, laminated 
amyloid bodies, lecithin granules, and finally Boettcher's char- 
acteristic "sperma crystals." These are needle-shaped and 
whetstone-shaped crystals, discovered by Schreiner (1878); 
they consist of a salt of phosphoric acid, are peculiar to the 
prostatic secretion, and give the characteristic odor to the 
latter and to the semen. In order to demonstrate them, 
the secretion of the prostatorrhcea must be examined pure, 
and in particular it must be kept free from admixture with 
urine. To a drop of the prostatic secretion is added a drop 
of a one per cent* solution of ammonia phosphate, and the 
mixture allowed to dry slowly under the cover glass; very 
beautiful crystals then form. 

An important question is that of the presence of gonococci. 

These are found so constantly and exclusively in acute 



Blenorrhcea of the Sexual Organs. 



irU 



gonorrhoea that their absence from an acute purulent secretion 
of the urethra excludes blenorrhcea unconditionally. The 
conditions ?n chronic gonorrhoea are not so favorable. Their 
number is small, thej 7 cannot always be found, and in addition 
other, in part similar, micro-organisms are also present. 

Goll (1891) made systematic examinations of numerous 
cases of urethritis with regard to the presence of gonococci 
and arrived at the f ollowing- results : 



Duration. 



4-5 weeks . . 

6 tl .. 

7 " .. 

2 months. 

3 " . 
4 

5 " . 
6 
7-9 

1 year . . . 
\\ years . . 

2 " .. 

3 " .. 

4 " .. 

5 " .. 



Number of 


Positive 


Negative 


Cases. 


Findings. 


Findings. 


85 


40 


45 


54 


21 


33 


35 


11 


24 


75 


15 


60 


76 


13 


63 


62 


13 


49 


43 


8 


35 


55 


8 


47 


108 


21 


87 


83 


12 


71 


76 


7 


69 


135 


7 


128 


80 


2 


78 


37 




37 


20 




20 


22 




22 



Percent- 
age. 

47 
38 
31 
20 
17 
21 
14 
14 
19 
14 

9 

5 

2.5 



Hence, the finding of gonococci in chronic blenorrhcea is 
inconstant. The clap shreds or pus drops may often be ex- 
amined for several days without disclosing the gonococci. 
Then they may reappear in larger or smaller numbers. 

But one circumstance often characterizes the gonococci: 
they take part in the exacerbations of the process to which 
they have given rise, by increasing in numbers. It happens 
not uncommonly that the secretion is examined for several 
days, and various bacilli and cocci, also diplococci, but no suffi- 
ciently characteristic gonococci are found. Then follows an 
exacerbation. At once the gonococci appear in the more 
abundant pus, and in particular we detect the characteristic 
pus cells, which are filled with numerous pairs of cocci. At 
the same time, the other forms of bacilli and cocci have dis- 
appeared as if by magic. The question is therefore justified 
whether the micro-organisms which are found in chronic ure- 
thritis, and which are, in part, identical with those found by 



152 



BlenorrJioea of the Sexual Organs. 



Lustgarten and Mannaberg in the normal urethra, can vege- 
tate in the blenorrhagic, inflamed and suppurating urethra. 
The question is an open one, but according to the views men- 
tioned above, it may be answered in the negative, particularly 
as the pus is always found free from micro-organisms in chemi- 
cal or traumatic suppurations from the urethra. 

In order to convince ourselves of the presence of gonococci 
in the secretion of chronic urethritis it is only necessary to in- 
duce an exacerbation or relapse. The patient himself often 




Fig. 19. 



does this. In other cases the physician stimulates the secre- 
tion for the purposes of diagnosis. It is sufficient to inject, by 
means of Ultzmann's injection catheter, a few drops of a \ to 
1 per cent, solution of silver nitrate in order to secure suppu- 
ration, which generally contains gonococci in abundance. In 
order to avoid confusion with other micro-organisms Neisser 
irrigates the urethra several times with a solution of corrosive 
sublimate (1 : 20000). An irritation develops and gives rise to 
suppuration and desquamation of the upper layer of cells. 
With the latter are removed the accidental micro-organisms 



BlenorrJioea of the Sexual Organs. 153 

adherent to them, while the gonococci, which proliferate in the 
tissues, remain intact and appear in increased numbers in the 
pus of the next few days. 

Nevertheless there are cases in which, despite repeated ex- 
aminations for several weeks and despite one or more artificial 
exacerbations, no positive results with regard to the discov- 
er of gonococci can be reached. In these cases we must ar- 
rive at the conclusion that the gonococci have perished, but 
that the changes produced by them continue to develop. The 
secretion then contains, as a rule, no pus cells, but numerous 
epithelial cells, and, in addition to other inconstant bacterial 
contaminations, in some cases narrow, short bacilli often ar- 
ranged in short chains upon the cells (Plate IV., Fig. 11). 
We therefore have to deal no longer with suppuration but 
w T ith epithelial desquamation. 

This is either the result of a process which has run its 
course, the epithelial thickening, or of increased epithelial des- 
quamation due to a micro-organism, but not of the blenor- 
rhagic process. 

We have already said that, in addition to gonococci, other 
bacteria are found in the chronic cases. These are not con- 
stant. There are always a large number of blenorrhoeas in 
which we find no gonococci or other micro-organisms. Then 
there are others in which, even in the terminal stage of the 
acute urethritis, various micro-organisms are found in ad- 
dition to the gonococci, and this is also true of chronic gon- 
orrhoea. 

The micro-organisms are mainly bacteria, more rarely cocci. 
The former include short and broad, narrow and long, or 
slightly curved comma-like forms which are found in short 
chains or groups usually free between or upon the cells. The 
cocci may be small and arranged in short chains or groups of 
chains, or somewhat larger diplococci about the same size as 
gonococci, or large spherical cocci in short chains; finally zoog- 
loea forms (Plate IV., Fig. 9). Petit and Wassermann (1891), 
but especially Janet(1892), have studied these micro-organisms. 
In regard to the gonococcus and these bacterial contaminations, 
Janet divides blenorrhcea into three phases : First phase, gono- 
coccus alone; second phase, gonococcus and bacterial con- 
taminations; third phase, bacterial contaminations alone. 
These different bacteria usually enter the urethra during 



154 Blenorrhcea of the Sexual Organs. 

coitus and find a good nutrient in the catarrhal membrane. 
They are capable of continuing' the process, and, after re- 
covery of the gonorrhoea proper, may produce a catarrhal, 
often obstinate, pseudo-gonorrhoea. 

I could never detect any gonococci or other micro-organ- 
isms in the secretion of prostatorrhcea, despite numerous in- 
vestigations. 

The question of the occurrence of gonococci in chronic clap 
is associated with, another important question, viz., 

The Infectiousness of Chronic Gonorrhoea. 

This question was answered differently at different times. 
Kuehn (1785) believed that when the secretion lost its puru- 
lent character, the danger of infection was gone. Hunter, B. 
Bell, Sallaba, Girtanner, Baumes and Ricord denied the infec- 
tiousness of an after-clap. On the other hand, Rossen, Simon 
and Geigei warned against trusting even the oldest clap. Gos- 
selin denies the infectiousness, while Milton reports several 
cases of infection by the secretion of old chronic urethritides. 
Neisser (.1884) was the first who studied the subject scientifi- 
cally. He proved that the infectiousness of chronic blenor- 
rhcea is a conditional one, in so far as the secretion may con- 
tain gonococci, that there are cases in which the secretion 
only contains the cocci at times, and finally others which 
are always found to be free from gonococci despite the most 
careful and frequent examinations. Furthermore, since the 
secretion is small in amount, and after being washed away 
by the urine requires a considerable time for its regeneration, 
it follows that a single act of coitus with an individual suffer- 
ing from chronic blenorrhcea does not necessarily produce in- 
fection. As the result of numerous examinations I concur in 
this opinion and permit a patient who is suffering from chronic 
blenorrhcea, i.e., the morning drop or clap threads, to have 
marital intercourse only after I have convinced myself by a 
two to four weeks' daily examination of the secretion or clap 
shreds that these contain only epithelium and no pus cells, 
and when, after irrigation of the urethra with a solution of sil- 
ver nitrate or corrosive sublimate and consequent suppuration, 
the secretion is entirely free from gonococci, and there is no 
further indication for the continuance of treatment. 



Blenorrhcea of the Sexual Organs. 155 

The conditions which I require are, accordingly, the ab- 
sence of gonococci, pus corpuscles, and peri-urethral compli- 
cations. These conditions have been since accepted by nu- 
merous authors, including- Brewer (1891), Goldenberg (1892), 
Janet (1892), and Letzel (1893). One condition I must espe- 
cially emphasize, viz., the absence of pus corpuscles. The 
presence of shreds or pus corpuscles in the secretion is al- 
ways an indication that the inflammation is not extinguished. 
It is possible that the inflammation still continues despite the 
disappearance of the gonococcus, its original etiological factor, 
but this will probably not be true of many cases. On the other 
hand, the question of the presence of gonococci is often an- 
swered with difficulty. Positive findings put the matter be- 
yond question, but negative findings do not prove that gono- 
cocci are not present. After long and laborious examinations 
with negative results the gonococci may suddenly reappear, 
so that I most urgently caution against answering the ques- 
tion with regard to marital intercourse from the results of 
bacteriological examination. This should be refused so long 
as pus corpuscles are present. 

Inasmuch as gonococci are often present in the secretion 
of the pars posterior but absent in that of the pars anterior, 
the examination of both parts should be performed separately. 
The shreds coming from the two localities may be separated 
by the irrigation test. If the pars anterior is washed from be- 
hind forward by means of the catheter introduced to the bulb 
and the patient is then allowed to urinate, the secretion of the 
pars anterior will be found in the water used for irrigation, 
that of the pars posterior in the urine. 

Localization. 

We have just described the various forms of chronic ure- 
thritis and their symptoms. 

This description shows a differentiation of chronic blenor- 
rhcea into recent and inveterate cases; in the former the clap 
shreds appear in cloudy, in the latter in clear urine. 

Chronic blenorrhcea also varies, not alone according to the 
extent of surface involved, but also according to the depth to 
which the process extends. In some cases it runs its course su- 
perficially upon the mucous membrane, in another group it ex- 



156 BlenorrJioea of the Sexual Organs. 

tends to the underlying 1 tissues, to the corpus cavernosum and 
the prostate. Hence the question always arises, Is the pro- 
cess situated in the pars anterior or posterior, or in both — 
is it purely mucous or is it complicated by submucous changes 
(periurethritis and circumscribed cavernitis for the pars an- 
terior, colliculitis seminalisand prostatitis glandularis for the 
pars posterior) ? 

An approximate localization is possible from the considera- 
tion of the symptoms and examination of the urine. Thus, a 
discharge from and agglutination of the meatus, indicates an- 
terior chronic urethritis of the pendulous and bulbous portions. 
Mucous cloudiness of the second portion of the morning urine, 
comma-like flocculi in the second portion, prostatorrhoea and 
neurasthenic symptoms favor the diagnosis of prostatic ure- 
thritis. But these symptoms are not conclusive, and their ab- 
sence does not exclude the localization in question. Thus, 
there may be a mild posterior urethritis in which the mucus 
does not enter the bladder on account of its small quantity 
and in which the glands are not implicated, so that no comma- 
like shreds are found in the second urine. The process is super- 
ficial, therefore no affection of the caput g-allinaginis, no neur- 
asthenic disturbances. Hence, if we confine ourselves to an 
examination of the patient, we will overlook the process in the 
pars posterior. This remains untreated, therefore becomes 
aggravated and finally leads to severe symptoms, which could 
have been obviated by early treatment. Hence the attempt 
was made at an early period to determine the site of chronic 
urethritis more accurately. Leroy d'Etiolles introduced into 
the urethra as far as the bulb a bougie which carried a small 
hidden sponge at the end. The sponge was then exposed and 
the bougie withdrawn, so that the pars anterior was cleansed. 
An ordinary bulbous bougie was then introduced into the pars 
posterior. If mucus or pus adhered to the tip, this could only 
come from the pars posterior. The following is Zeissl's method : 
The patient, who has not urinated for several hours, receives 
an injection of pure water into the pars anterior in order to 
wash away any flocculi contained therein. After the water, 
which at first contains shreds, escapes clear, the patient is 
allowed to urinate. If the urine then contains shreds, they 
must be derived from the pars posterior. A better plan than 
that of injection with the clap S3'ringe, as performed by Zeissl, 



Blenorrhosa of the Sexual Organs. 157 

is that of inserting an elastic catheter as far as the bulb, per- 
forming* recurrent irrigation of the pars anterior, and then 
allowing the patient to urinate. 

Kromayer (1892) has recently recommended a very prac- 
tical method. After the patient has retained his urine for 
several hours, a solution of methyl blue is injected with the 
clap syringe. This passes to the bulb and is allowed to re- 
main one or two minutes. The patient then urinates. The 
shreds from the pars anterior are stained with the methyl 
blue, those from the pars posterior have a white color. 

The French, especially Guyon, Jamin, Guiard, use a bulb- 
ous sound, " sonde exploratrice," with which they first remove 
the pus from the pars anterior by rotatory movements and 
repeated introduction, and then pass into the pars posterior, 
If mucus or pus is then found on extraction, the process is sit- 
uated in the pars posterior. 

A frequently used method, which is "based on the fact that 
the locus morbi in the urethra is sensitive and painful, is ex- 
amination with the sound or bulbous bougie. If this is intro- 
duced slowly into the urethra, the patient not alone feels pain, 
which always results from the examination and is felt particu- 
larly in the membranous portion, but he not infrequently de- 
scribes a burning or stitch pain in certain fixed points. If the 
examination has been made several times, and the pain is 
always localized in the same parts, we wall hardly err in re- 
garding these spots as the site of urethritis. If the process is 
localized in the pars prostatica the passage of this part usu- 
ally causes a violent, painful tenesmus, and the withdrawal of 
the sound is followed by the prostatorrhceic secretion. In 
cases of urethral hyperesthesia in neurasthenics sounding is 
very painful. The sound is arrested every moment by spasm 
of the urethra, passage of the membranous portion is arrested 
by the spasm, which only subsides at the end of a few min- 
utes, and even the removal of the sound is made difficult from 
the same cause. 

Although examination with the sound only informs us con- 
cerning the site of the disease (and this not very reliably), it 
possesses one advantage over the other methods. If the 
sound has the largest possible calibre which the meatus w T ill 
admit, the examination proves that there is no notable narrow- 
ing of the urethra. 



158 Blenorrlicea of the Sexual Organs, 

The chronic foci, consisting' of connective-tissue hyperpla- 
sia, diminish the elasticity or dilutability of the mucous 
membrane. This will be so much more marked, the greater 
the amount of surface and the depth involved, and the 
greater the transformation into fibrillary connective tissue. 
In the succulent infiltrations of the first stage the diminution 
of dilatability is slightest. If the dilatability of the urethra 
were uniform, its diminution could be demonstrated by 
eve^ sound which passes the meatus. But this is not 
so. The meatus is the most rigid part of the entire canal. 
In order to convince ourselves that the elasticity of the 
pars cavernosa has not been diminished, we must be able to 
stretch the bulb to 40-45 Charriere, the pendulous portion to 
30-35 Charriere. Hence there may be infiltrations which 
allow the passage of any sound that is capable of passing the 
meatus. These infiltrations retract in time and become no- 
ticeable when they have reached, a smaller calibre than the 
orifice. Otis calls these wide strictures and believes that there 
is no chronic urethritis without some, though perhaps slight, 
narrowing. These stenoses do not always deserve the name 
stricture, inasmuch as they have not developed from connect- 
ive-tissue retraction but from infiltration and swelling of the 
mucous membrane. It is nevertheless certain that even con- 
nective-tissue strictures, in their incipiency, may escape our 
knowledge. Otis and Weir recommend the use of their ure- 
thrometer in order to recognize these wide strictures. If the 
closed instrument is inserted in the normal urethra, tthe olive 
or spindle is readily separated in the bulbus to 40-45-50, and 
in the pendulous portion to 30-35-45. This separation cannot 
be effected when infiltrations diminish the elasticity of the ure- 
thra. If we begin at the bulb and measure the distensibil- 
ity of the entire urethra, we can obtain data concerning 
the site of the infiltration by the diminution of the dilatability 
of the canal in circumscribed spots, concerning the density of 
the infiltration by the greater or less diminution of dilatability, 
and concerning the succulence or resistance of the infiltration 
by the greater or less resistance to further dilatation. If, as 
happens not infrequently, the dilatability for the urethro- 
meter is not diminished despite a demonstrable lesion in the 
pars anterior,' we have to deal with succulent, very superficial 
mucous foci. 



Blenorrhoea of the Sexual Organs. 



159 



All these methods give us the situation of the chronic proc- 
ess, but not a picture of it. This can only he obtained by 
the use of the endoscope, which is often indispensable for 
diagnosis. 

The notion of examining the mucous membrane of the 
urethra by means of apparatus similar in principle to the 
vaginal speculum, dates back to the beginning of this century. 
But the instruments inserted in the urethra have such a nar- 
row lumen and permit the entrance of so little light, that con- 
centration of the rays of the source of light and their reflection 




in the tube of the endoscope, were made necessary. Segalas 
was the first who grasped this idea, but Desormeaux was the 
first to execute it completely. He also founded the pathol- 
ogy of chronic urethritis in a manner which left little to be 
changed. 

Desormeaux's instrument (Fig. 20) consisted of a funnel- 
shaped urethral tube, at the end of which was fastened the 
illuminating apparatus. This consisted, in principle, of a per- 
forated reflector, placed obliquely in a tube, and which re- 
ceived its light from a lamp placed on one side, while the eye 
of the observer looked through the central opening in the mir- 



i6o 



Blenorrhcea of the Sexual Organs. 



ror. Apart from the weight of the instrument it possessed the 
disadvantage that it was adapted for study but not for local 
interference. After a series of changes had been made in the 
source of light, others made more material changes, the most 
important of which is the complete separation of illuminating 
apparatus, reflector and tube; this was first conceived by 
Hacken. Gruenfeld used for illumination a gas or oil lamp, as 
reflector a laryngoscopic mirror which can be fastened to the 




Fig. 21. 



Fig. 22. 



forehead, and a series of endoscopic tubes (Fig. 21), long and 
short, fenestrated anteriorly or laterally, and with the fenestra? 
either open or closed with plane glass, destined for various 
parts of the urethra and bladder. Steurer's modification (1876) 
was a practical improvement of the endoscopic tubes. The 
Gruenfeld tubes, with a calibre of catheters of 18 to 24 Char- 
riere, pass gradually at the ocular end into a tolerably wide 
funnel, which is blackened inside like the endoscope, and whose 
serrated rim serves for the conduction of the instrument. The 



Blenorrhoea of the Sexual Organs. 



161 



introduction of the instrument into the urethra to such a dis- 
tance as to cause painful distention of the meatus by the fun- 
nel is almost unavoidable. Steurer uses shorter tubes (Fig 1 . 22), 
which 'render better illumination possible, and then inserts a 
round plate into the tube at the point where it passes into the 
funnel. The fixation and conduction are thus facilitated ma- 
terially, while the plate permits the painless shoving" together 




i 



Fig. 23. 



of the penis in examination of the deeper parts and thus the 
use of shorter tubes. In order to make larger parts of the 
urethra visible, Auspitz (1879) recommended a bi-valve endo- 
scope (Fig. 23), which is inserted with the conductor closed 
and is then opened, and, being formed after the manner of 
Cusco's duck-bill speculum, does not distend the orifice. In- 
stead of the ordinary rounded conductors which project 
11 



1 62 



Blenorrhcea of the Sexual Organs. 



slightly beyond the tube, Schuetz (1886) uses an olive-tipped 
bougie, which is introduced into the posterior portion of the 
urethra, and over which the endoscope is inserted. Posner 
recommends tubes which are bright inside, like Ferguson's 
speculum, instead of blackened tubes. In order to see larger 
surfaces of the pendulous portion, Autal devised his aero- 
urethroscope, a short endoscopic tube which is applied firmly 




to the glans by a sort of cap, and 
is closed above by a glass fenes- 
tra. By means of a bulb on the 
side of the tube air is blown into 
the urethra and separates its 
walls, and thus permits a view 
of a larger area, which is always 
anaemic from the pressure of the 
air. Gruenfeld also mentions a 
method of auto-endoscopy for 
the benefit of specialists who 
may be suffering from chronic 
urethritis. 

The introduction of electric 
lights has led to the construc- 
tion of new apparatus — for ex- 
ample, Oberlaender's modifica- 
tion of Nitze-Leiter's instrument. This consists of endoscopic 
tubes, but the source of illumination, a white-hot platinum 
wire, is situated at the visceral end within the tube. In order 
to prevent the conduction of heat from the wire to the instru- 
ment and mucous membrane, a thin column of fluid flows 
around the wire. Although made very compactly the appara- 
tus nevertheless narrows the lumen of the endoscope, apart 
from the fact that the attention of the examining physician is 
diverted by the battery and the conduction of water. The source 
of light is often too vivid, and offers the disadvantages which 



Fig. 24. 



Blenorrhoea of the Sexual Organs. 163 

always become noticeable when one looks from the dark into 
a brightly lighted space. Schuetz's diaphotoscope (1887) has 
the source of light— an arc lamp and reflector— immediately 
in front of the eye. 

The Leiter electro-endoscope constitutes the most servicea- 
ble and practical improvement. This returns to the principle of 
the Desormeaux endoscope. It consists of short endoscopic 
tubes, fashioned after Steurer's, at whose ocular end is applied 
the easily-handled illuminating apparatus by means of its 
funnel- shaped end. The illuminating apparatus (Fig. 24) is 
connected by two wires with the battery, and consists of an 
arc lamp and behind it a fixed concave mirror, which throws 
the rays of light parallel into the funnel and through those 
into the endoscope. The eye of the observer looks over the 
rim of the mirror into the funnel, and tampon, brush and other 
instruments are introduced in the same direction. The vivid- 
ness of the illumination may be varied by raising or lowering 
the elements in the cells. 

Technique of Endoscopy. — At the present time we use 
only short straight tubes, like those recommended by Steurer. 
The introduction of the straight instrument into the urethra 
is attended with some difficulty for the beginner. The well- 
oiled instrument should be led along the upper wall of the 
urethra as far as the bulb, but not pressed too far into it; the 
ocular end is depressed, with coincident slight pressure upon 
the visceral end of the instrument, in order to enter the isthmus, 
and then the instrument pushed forward to the neck of the 
bladder, i.e., until urine begins to escape between the instru- 
ment and conductor when the bladder is moderately full. 
Slight traction now brings the apparatus immediately in front 
of the internal prostatic sphincter. The examination of the 
urethra is always conducted from behind forwards, the con- 
ductor being removed and the field of vision cleaned with 
tampons. 

The patient should be placed upon a table (Fig. 25) which 
is at the level of the eye of the physician sitting in front of 
it. For examination of the neck of the bladder and pars pros- 
tatica the ocular end of the instrument must be depressed 
considerably. The patient's genitalia must be raised in order 
to see well. For this purpose it is well to have the lower end 
of the table movable at an angle by means of a screw. Small 



164 



Blenorrhcea of the Sexual Organs. 



drawers under the table, containing' tampons, caustic-holders, 
etc., render assistants superfluous. The patient lies in the 
horizontal position with the head slightly elevated, the lower 
limbs flexed and kept in the most comfortable position by 
means of the foot rests. The best tampon-carriers are little 
rods of wood, which can be obtained in match factories. A 
little cotton is wound firmly around one end and the rod thrown 
away after being used once. Very serviceable tampon -carriers 
are also made of firm iron wire, the visceral end, around which 
the cotton is wound, being filed down and slightly serrated. 
After using the cotton is burnt in a spirit lamp, thus securing 
at the same time the best sterilization of the wire. 




Fig. 25. 

In examining' the normal urethra we notice, in the poste- 
rior portion of the pars prostatica, that the mucous membrane 
passes from the rim of the endoscope to a quite centrally situ- 
ated point, in which it comes tog-ether like a sphincter and 
thus forms a short funnel. The color of the mucous mem- 
brane is quite dark red, its surface smooth or slightly ridged 
by delicate longitudinal folds, which all pass towards the apex 
of the funnel, and are called the "central figure." 

As the endoscope is withdrawn the mucous membrane at 
the apex of the funnel follows, so that the funnel always re- 
mains the same. At the same time we notice a gradually 



Blenorrhcea of the Sexual Organs. 165 

increasing- pallor of the mucous membrane. If we withdraw 
the tube a little, we will notice that, while the funnel remains 
intact above and laterally, a flat or round, protuberance pushes 
into the lumen of the endoscope from below or often from be- 
low and on the left side, and becomes clearly visible on with- 
drawing- a little further. This is the caput gallinaginis, which 
has a quite uniform carmine color and occupies about three- 
quarters of the field of vision. To the right and left are two 
dark furrows; above it the funnel, which is reduced to the 
shape of a crescent. In favorable cases, especially if the caput 
is brought entirely into the lumen by lifting- the ocular end of 
the tube, we see upon the prominence the opening of the pocu- 
lar, like the point of a needle. 

On further withdrawal the caput gallinaginis passes back- 
wards, but its prolongation remains visible for a considerable 
period as a large fold on the lower surface of the funnel. In 
consequence of the projection of the caput gallinaginis, the 
central figure forms a short curve, with the convexity above, 
the concavity below and a little to one side, and which grows 
constantly smaller from behind forwards. Finally we arrive 
at a point where the mucous membrane, which gradually grows 
paler, again forms a complete funnel with punctate central 
figure, and the mucous membrane is smooth or slightly ridged 
radially towards the central figure. We are then in the mem- 
branous portion. So long as we remain there, the appearance 
of the short, pale-red funnel is the same. Next follows a spot, 
which may prove especially confusing to the beginner. On con- 
tinuing the slow withdrawal we leave the membranous portion. 
As soon as we are out of the isthmus, the visceral end of the 
endoscope enters the field of activity of the bulbo-cavernosi 
and ischio-cavernosi muscles, which push it upwards with rapid 
contractions. In order to counteract this movement, which 
may even expel the instrument if held too lightly, it is sufficient 
either to lift the ocular end and to carry on the further con- 
duction of the endoscope in the same way as a catheter (in a 
curve directed towards the abdominal walls), or the visceral 
end of the instrument must be kept below the symphysis by 
pressure from without. The action of the bulbo-cavernosi and 
ischio-cavernosi muscles is visible in the endoscope. The funnel 
hitherto formed by the mucous membrane disappears. The 
contraction of the muscles which are situated on the sides of 



1 66 Blenorrhcea of the Sexual Organs. 

the urethra, pushes the mucous membrane into the endoscope 
in the shape of two lateral ridges, which touch in a vertical 
fissure in the middle of the field of vision. This picture persists 
throughout the entire pars bulbosa, except that the vigor of 
the muscles, and hence the width of the ridges, diminishes an- 
teriorly. In this situation the color of the mucous membrane 
is subject to the greatest variations; it may be entirely anae- 
mic as the result of pressure, but is normally of a pale flesh 
red. On careful examination of one or the other wall we can 
see not infrequently the Morgagni's lacunas as dark spots sur- 
rounded by a narrow ring of darker red mucous membrane. 

On passing into the pendulous portion the funnel of the 
very pale red mucous membrane again appears. This funnel 
is so much longer the more the pars pendula is stretched, and 
in this way a large portion of the mucous membrane may be 
brought into view. Radial folds are not infrequent, and Mor- 
gagni's lacunae are often visible. 

With regard to the appearances in chronic urethritis the 
endoscope possesses the great advantage that it allows us to 
recognize not alone the site of the changes but also their 
nature. The endoscopic picture is essentially the same in 
pathological cases as in the normal, but undergoes certain 
modifications from the swelling and infiltration of the mucous 
membrane. When it forms a funnel with a punctate central 
figure, the funnel will suffer in all its dimensions by the uni- 
form succulent swelling, and will become narrower and shorter. 
If the swelling is very considerable, the mucous membrane 
will even project into the tube, and the funnel will start from 
this projection; it is therefore very small, narrow and low. If 
there is rigid, though uniform, swelling of the mucous mem- 
brane, the latter will not come in contact so rapidly, and the 
funnel will be longer and higher. Unequal, unilateral or dis- 
seminated infiltrations and swellings will make the funnel 
un symmetrical; swollen folds appear distinctly and disturb the 
punctate shape of the central figure, which is distorted, oval, 
or formed of several contours which are convex internally. 
Where no funnel is formed, but the mucous membrane is ridged, 
as in the bulb, the ridges project into the tube to a greater 
extent if the swelling is succulent, but are not prominent if 
the swelling and infiltration are rigid. Indeed, it is found not 
infrequently that no ridges are formed, and the mucous mem- 
brane incloses the field of vision like the wings of the stage. 



Blenorrhoea of the Sexual Organs, 167 

The changes in the surface consist, in the first place, of 
differences in color. Various shades from red to dark red and 
bluish red may be found diffused or disseminated in different 
parts of the urethra. 

The surface may also appear changed, apart from the 
color. It may look smooth and shining in the diseased parts, 
but more frequently it has a dull look. In many cases it is seen 
that this dull appearance depends on epithelial losses, which 
give the surface a finely stippled appearance. Or the surface 
shows a velvety roughness. In still others it is cloudy, looks 
swollen, has lost the smoothness of normal mucous membrane, 
and is covered with a large number of dark-red grains, which 
may be uniformly of the size of small grains of sand, or they 
are unequal, with a pointed, conical or round top, and present 
the appearance of a mulberry or a granulating wound. This 
change, known as granulation, may occupy large surfaces or 
appear as small, circumscribed patches. Certain circum- 
scribed affections also occur, as swelling of Morgagni's lacunas, 
with erosion of the vicinity of the excretory ducts, intense red- 
ness, irregular superficial ulcerations, and patches of thick- 
ened and opaque epithelium. Finally, in addition to the 
previously described granulations (which often attain consider- 
able dimensions from loosening of the tissues and fungous 
proliferation), are found true trachomatous granules, which 
are succulent, and shine through the delicate mucous mem- 
brane like frog spawn (Gschirhakl, 1878; Gruenfeld, 1880). 

We thus have a picture of gTeat diversity, which is so much 
greater because all the changes mentioned may be present in 
the same urethra. But certain changes are found mainly in 
certain portions of the canal. 

If we examine the urethra in these cases from behind for- 
wards, we will find at the neck of the bladder, in addition to 
a very small, or, as the result of rigid infiltration, very wide 
and high funnel, that the mucous membrane has a deep livid 
redness, the folds which radiate from the central figure are 
more distinct, here and there (usually isolated) a larger ero- 
sion, which bleeds at once when touched with the tampon. In 
cases of chronic prostatic urethritis the caput gallinaginis is 
considerably swollen, the mucous membrane livid and velvety, 
and pressure with the tampon causes violent pain. The pallor 
of the remainder of the mucous membrane usually contrasts 



1 68 Blenorrhcea of the Sexual Organs. 

with the dark redness of the caput gallinaginis. I have never 
found granulations in the pars prostatica, but Desormeaux 
describes them. 

In the membranous portion we usually find only swelling, 
redness and small erosions. Granulations occur not infre- 
quently in the anterior portion, bat their proper territory is 
the bulb, which they often fill in great measure. The pendu- 
lous portion presents the most manifold picture. Patches of 
granulations and thickened and cloudy epithelium alternate 
with simple catarrhal swelling, redness, and erosions. 

For this reason it is inadvisable to divide chronic urethritis 
into urethritis simplex, granulosa, trachomatosa, etc. All the 
changes seen by us in chronic urethritis are phases of one and 
the same process, which may occur together or follow one an- 
other. This is explained by the fact that the process has its 
sites of predilection to which it is chiefly confined and in which 
it reaches its highest development, while in other places it does 
not run such a severe course or is complicated b} T secondary 
changes. 

We will now give a brief resume of the method of exami- 
nation which I have found to be practical. 

If a patient tells us that he is suffering from chronic ure- 
thritis, we first take the previous history (duration, frequency 
of infection, etc.), inquire concerning previous complications 
(cystitis, epididymitis, prostatitis) and other symptoms such 
as prostatorrhoea, spermatorrhoea, sexual weakness and im- 
potence. We then examine the patient. Any secretion which 
may be squeezed from the urethra is placed on the object glass, 
dried, stained, and examined microscopically for gonococci and 
leucocytes. The patient then urinates in two portions. Cloudy 
urine with clap shreds indicates more recent urethritis. If the 
second portion is also slightly cloud} 7 , or if the second portion 
is clear but contains Fuerbringer's comma-shaped hooklets, 
then posterior urethritis is undoubtedly present. If the first 
urine is cloudy, or if it is clear but contains clap shreds, while 
the second portion is entirely clear, then localization is impos- 
sible for the present. 

The patient is directed to report upon the following day 
and to retain the urine several hours prior to his visit. 

At this second visit we perform the irrigation test. The 
shreds in the irrigation water are reserved for microscopical 



Blenorrhoea of the Sexual Organs; 169 

examination. If the shreds are found only in the former but 
are absent from the urine passed after irrigation, the case is 
one of anterior urethritis. 

Examination with the urethrometer then shows whether 
the lesion is superficial or deep. 

If shreds are found in the urine after washing out the pars 
anterior, i.e., in case of posterior urethritis, the differentiation 
between a purely mucous process or coincident affection of the 
prostate is shown by the presence or absence of prostatorrhcea, 
spermatorrhoea and impotence. In the latter event examina- 
tion of the pars posterior with the bougie a boule will disclose 
an} 7 enlargement of the caput gallinaginis which may be pres- 
ent, and examination (as regards pus) of the secretion evacu- 
ated on the bougie or after pressure upon the prostate 
through the rectum (performed immediately after micturition) 
may amplif}- the diagnosis by disclosing catarrh of the pros- 
tatic glands. 

Pathological Anatomy. 

The nature of chronic urethritis, like that of the acute 
form, long remained obscure. Thus, Swediaur (1798) regarded 
the prostate as the site of gleet and the secretion as an 
"unnatural discharge of the mucus of this gland. Girtanner 
(1803) regarded gleet as a weakness of the mucous glands. 

Desruelles (1854) had the opportunity of making an autopsy 
on an old man who died of pleurisy and had suffered for twenty 
years from chronic urethritis. He found a number of yellow- 
ish-white granulations, which were situated mainly in the 
membranous portion; the remaining mucous membrane of the 
urethra was delicate, pale and thin. According to Civiale, 
his pupil Lewy had observed (1850), in an autopsy on a strict- 
ure patient, numerous fine, dirty gray granulations in the 
prostatic portion behind the stricture ; but little attention was 
paid to these appearances. 

Desormeaux (18f>5) described the appearances in chronic 
urethritis from his examinations in the living, and called es- 
pecial attention to the granulations. As an adherent of Thiry's 
(1840) doctrine of a " virus granuleux," he regarded them as a 
characteristic not alone of chronic but also of acute blenor- 
rhoea. In addition to red granulations, like those of proud 



1 70 Blenorrhoea of the Sexual Organs. 

flesh, Desormeaux described gray granules like those of tra- 
choma. 

Soon afterward Cullerier reported two autopsies on old 
urethritides. In the first case, a young man who had died of 
typhoid fever and was said to have suffered only thirty-three 
days from clap, there was dark-violet redness of the entire 
anterior part of the urethra, where the mucous membrane was 
thickened and rough. On the lower wall of the urethra, in the 
pars prostatica, he found about twenty small red nodules, sur- 
rounded by a circle of injected capillaries, exactly like the gran- 
ulations found on the ocular conjunctiva. Similar changes 
were seen in another case of urethritis two months old. 

Fauconnier was the first to furnish a detailed account of 
an autopsy in a man, aet. thirty-two years, who entered Guyon's 
wards on January 15, 1877, suffering from a chronic urethritis 
of seven years' standing and a recent syphilis. He died of 
facial erysipelas. Examination of the urethra (Plate V., Fig. 
12) showed : at the neck of the bladder, near the caput gal- 
linaginis, the mucous membrane was whitish, non-vascular, 
as if cicatrized. The caput gallinaginis was enlarged and 
thickened. Pressure on the ejaculatory ducts discharged 
prostatic secretion mixed with pus. In the membranous por- 
tion the mucous membrane appeared pale, smooth, like a cica- 
trix, and traversed by longitudinal vessels. The mucous 
membrane of the bulb is sharply defined posteriorly, while 
anteriorly over a surface of about 6 centimetres it is uneven, 
dull, eroded in some places, congested, covered with extremely 
fine, whitish granulations, which are especially dense in the 
bulb and resemble a granulating wound. The pars cavernosa 
is normal except a strongly injected portion anteriorly, about 
5 centimetres long. No trace of narrowing or fibrous thicken- 
ing in the entire urethra. Microscopical examination of the 
granulations showed small cell infiltration. 

Soon after appeared two interesting examinations by Vajda 
(1882). In two cases of old chronic urethritis, in one of which 
a stricture and peri-urethritis were also present, he observed : 
1. Thickening of the epithelium, attended with flattening, so 
that the cylindrical epithelium of the urethra finally disap- 
peared entirely. 2. The newly formed epithelium masses are 
collected especially at the apices of newly formed hypertro- 
phic papillae and protuberances, which formed excrescences and 



Finger: 



Plate V. 







Fig.12. 



UNDNER, EDDY 4 CLAUSS, LITH. 



Blenorrhoea of the Sexual Organs. 171 

finally papillomata. 3. The papillomata and epithelial thick- 
enings increased in the deeper parts of the urethra. 4. The 
connective tissue around the urethra is infiltrated. 

In the Atlas des maladies des voies urinaires of Guy on and 
Bazy are found two cuts of anatomical preparations of chronic 
urethritis. In one the urethra is normal as far as the bulb. 
Here the mucous membrane is congested and slightly exco- 
riated, sharply denned posteriorly, but gradually merging an- 
teriorly into normal membrane. In the second case granula- 
tions and small ulcerations are found in the bulb, but gradually 
disappear anteriorly. 

In Gosselin/s case, reported by Gueillot, the fossa navicu- 
laris and the bulb were found affected. In the latter the mu- 
cous membrane was violet in color, traversed by dendritic ves- 
sels, which gradually disappeared anteriorly. 

In Prof. Weichselbaum's laboratory I have recently made 
numerous histological examinations of the male urethra in a 
condition of chronic urethritis, and will here give a resume of 
the results : 

I. Anatomo-Pathological Changes of the Pars 
Anterior. 

The hyperemia, serous swelling and infiltration, winch are 
observed with the endoscope so often during life, either disap- 
pear post mortem or become less recognizable. 

There are, however, numerous macroscopic changes. The 
epithelium exhibits changes which vary from slight opacity to 
considerable thickening and whitish discoloration; the latter 
condition often simulates superficial cicatrices. Losses of 
epithelium are much rarer than thickenings, and are usually 
superficial and isolated. I never found extensive erosions or 
ulcerations. 

The changes in the subepithelial tissue, the swelling and in- 
filtration which depend upon hyperasmia, are indistinct on ac- 
count of the disappearance of the hyperasmia. Only one group 
of cases exhibited changes of the surface which were due to 
swelling. In circumscribed spots the surface appeared finely 
ridged, uneven, containing small nodules whose size varied 
somewhat. These were undoubtedly granulations, as was 
shown by the microscopical examination. 



172 Blenorrhoea of the Sexual Organs. 

There are striking" changes in Morgagni's lacunae. On sec- 
tion of the normal urethra these are invisible or appear as very 
fine dots. In a series of cases of chronic urethritis the open- 
ings are as large as the head of a pin and with the surrounding 
parts may be elevated like a crater. In another group of cases 
the lacunae are absent, and they are replaced by milky-white 
nodules, which are imbedded in the mucosa. 

With the unaided eye it is often impossible to distinguish 
cicatrices from simple epithelial thickenings. This is particu- 
larly true of ridge- and net-shaped, slightly elevated strictures, 
which are formed in part by epithelium, in part by subepi- 
thelial connective tissue. 

Non-constricting, depressed, eccentrically retracted callos- 
ities are not infrequent. Examination shows that they are 
always very superficial and due to changes in the uppermost 
layers of the subepithelial connective tissue. 

There are numerous interesting microscopical changes. In 
a series of cases the epithelium still retains its normal arrange- 
ment, but the uppermost layer of cylindrical cells is loosened 
and in a condition of mucoid degeneration. The transition 
cells, consisting normally of one or two rows, are often spread 
over many rows (Plate VI.. Fig. 13, a). Numerous pus cor- 
puscles are imbedded between the cylindrical and transition 
cells. Another interesting change is the transition of cylin- 
der into pavement epithelium. Three types of pavement epi- 
thelium may be distinguished : 

(a) It resembles that of mucous membranes with pavement 
epithelium, i.e., it consists of an undermost layer of cubical 
cells, several layers of polygonal, and an upper layer of pave- 
ment epithelium. 

(b) The epithelium is epidermoidal, consists of a lower layer 
of cubical cells, followed by several layers of polygonal or 
spindle-shaped cells analogous to the rete Malpighii; these 
cells constantly grow larger and flatter towards the surface 
(Plate VI., Fig. 15, a). 1 

(c) The epithelium is like that over cicatrices and consists 
of several layers of very flat pavement epithelium (Plate VI., 
Fig. 16, a). 

This conversion of cylindrical into pavement epithelium, 
which causes a xerosis of the mucous membrane, is connected 
with the changes in the subepithelial connective tissue. Thus 



Finger 



Fig. 13. 



Plate VK 








^&'S 



x-^.^ 






W^-V i 






"•"-». -t.V.v$<='^t'"i-"?r , <-/' 



F/tf. 1^. 



f 



... " • 



Jlrll 



Fig. 15. 




■fill 






WMm 



P4 



./y, ^,7'f® 



i&SS&^&fcfr- 






.--^ 



Blenorrhcea of the Sexual Organs. 173 

the first type of cells is found over recent round-cell infiltra- 
tions, the second type over older ones, the third form exclu- 
sively over firm connective tissue. 

The subepithelial connective tissue exhibits the most im- 
portant changes, and is the site of the chronic inflammatory pro- 
cess proper. This consists of an infiltration of the connective 
tissue, which has a decided tendency to transformation into 
retracting- connective tissue. In the more recent cases we find 
that the subepithelial connective tissue, sometimes only in the 
upper layers, sometimes extending- even into the corpus caver- 
nosum, contains a loose or dense infiltration, consisting of mono- 
nuclear and epitheloidal cells, sometimes mixed with pus cells. 
This infiltration surrounds the lacunae and glands imbedded in 
the subepithelial tissue, hence it is also perilacunar and peri- 
glandular. 

In a group of cases the cellular infiltration contains numer- 
ous, evidently new formed, very wide blood-vessels. These 
two factors, viz., the infiltration and the blood-vessels, give to 
the subepithelial connective tissue that papillomatous appear- 
ance, that mulberry-like condition of the mucous membrane 
in places which we described as granulations (Plate VI., Fig. 
13, 6). The infiltration consists at first of round and epitheloidal 
cells; as it grows older the spindle cells become more abun- 
dant. The interfibrillary tissue becomes denser and firmer, and 
there finally results a tissue which resembles a cicatrix ana- 
tomically. It is not due to ulceration but to chronic connec- 
tive-tissue hyperplasia. The granulations which may have 
formed during the recent stage are flattened by the retraction 
and a callosity results. This corresponds to the infiltration of 
the first stage; it is always circumscribed, sometimes located 
superficially in the uppermost layers of the subepithelial con- 
nective tissue, sometimes it extends deeply, even into the cor- 
pus cavernosum (Plate VI., Fig. 16, b). 

The stage of infiltration and of cicatrization may be compli- 
cated temporarily by exacerbation of acute inflammation and 
emigration of leucocytes. 

The lacunae exhibit changes analogous to those in the mu- 
cous membrane. The epithelium shows desquamation of the 
cylindrical cells, proliferation of the transition cells, transfor- 
mation into pavement epithelium (Plate VI., Fig. 15, a). The 
infiltration in the perilacunar tissue often raises the lacunae and 



174 Blenorrhcea of the Sexual Organs. 

dilates their lumen. If the infiltration in the connective tis- 
sue retracts, the lacunae will become atrophic and disappear. 
Not infrequently the outlet is first narrowed, and the lacuna 
is then converted into a little cyst, filled with pavement epi- 
thelium. 

Littre's glands, which are situated in the meshwork of the 
corpus cavernosum, exhibit two kinds of changes. In one the 
change is periglandular; the small-celled infiltration of the 
subepithelial connective tissue around the excretory ducts of 
the glands draws them downward and surrounds the gland and 
its duct. The excretory duct also exhibits epithelial changes 
which imitate those found upon the free surface, viz., the three 
types described above. Special interest attaches to the second 
type, in which the epithelium resembles that of the rete Mal- 
pighii. This is developed excessively in the excretory ducts, 
even extends into the body of the gland (Plate VI., Fig. 14, a, 
6), pushes beneath the secreting glandular epithelium and 
leads, by compression, to destruction of the acini. The secret- 
ing epithelium merely exhibits passive changes, viz., destruc- 
tion by the periglandular infiltration, which penetrates into the 
network of the acini. 

Exacerbations of acute inflammation with emigration of 
pus corpuscles can also be demonstrated in the glands and 
their excretory ducts. 

In a number of cases the corpus cavernosum is entirely in- 
tact. It may also take part in two ways in the chronic inflam- 
matory process. 

In one series of cases the chronic infiltration remains in the 
main superficial. It only enters the corpus cavernosum along 
the excretory duct and around the bodies of Littre's glands. 
This periglandular infiltration compresses not only the glands, 
but the adjacent spaces of the corpus cavernosum are also 
drawn into the retraction process. The corpus cavernosum 
then appears to be traversed by an entire series of cicatricial 
connective-tissue bands (Plate VI., Fig. 16, c). 

In another series of cases the chronic infiltration, which 
occupies the entire thickness of subepithelial, periurethral tis- 
sue, also penetrates the corpus cavernosum; here it remains 
superficial or occupies its entire width. In the first stage of 
the small-celled infiltration the trabecular of the corpus caver- 
nosum appear enlarged and infiltrated with numerous round 



Blenorrhcea of the Sexual Organs. 175 

(later spindle) cells. If this infiltration, which is alwaj^s cir- 
cumscribed, undergoes retraction, the mucosa and corpus cav- 
ernosum are converted into a firm, retracting- callosity. These 
deep-spreading callosities are the causes of stricture. 

Wassermann and Halle (1891) have confirmed these findings, 
and we are therefore warranted in defining stricture as the 
result of chronic cirrhotic periurethritis and cavernitis, which 
complicate chronic urethritis. 

Hence we must distinguish, in the pars anterior, two forms 
of the chronic process : a purely mucous, superficial form, which 
results in superficial, non-constricting, excentrically retracting 
cicatrices, and a second form, in which the process extends to 
the periurethral tissue and corpus cavernosum and thus leads 
to stricture. 

II. The Anatomo-Pathological Changes in the Pars 

Posterior. 

In the dead body this is characterized macroscopically by 
loosening of the mucous membrane of the urethra within the 
pars prosta tica. In some cases this gives to the mucous mem- 
brane a speckled look, in others it leads to the formation of 
delicate papillary excrescences which impart a villous ap- 
pearance. 

This papillary condition of the mucous membrane is usually 
most marked around the caput gallinaginis and also extends 
to the latter but is gradually lost upon its sides. It also di- 
minishes posteriorly towards the bladder and never reaches 
the vesical orifice. 

In other cases the mucous membrane shows thickening, 
callous degeneration, formation of firm connective tissue. 

The caput gallinaginis shows interesting changes. It is 
usuall} 7 enlarged, often to a marked degree. This enlargement 
is uniform. In only one case was it irregular and then con- 
sisted of numerous nodules with intervening shallow depres- 
sions. 

In a series of cases the mucous membrane of the caput gal- 
linaginis appeared loose, stippled, and also papillated upon the 
sides. In others it was rigid and callous. 

I directed special attention to the prostatic secretion. 
After laying the urethra open, I expressed this secretion from 



176 Blenorrhcea of the Sexual Organs. 

the prostatic duct by pressure upon the prostate. In six cases 
this secretion was thin, milky, and normal macroscopically as 
well as microscopically. 

In another group of six cases the secretion was thicker in 
consistence, more abundant, and had a milky-white color. 

Microscopical examination permitted a division of these 
cases into two groups : 

1. In one group the prostatic secretion, which is otherwise 
normal, contains an unusual number of epithelial cells (cylin- 
drical, cubic, polygonal). 

2. In the second group the secretion also contains a layer 
or smaller number of polynuclear leucocytes (pus cells). 

The anatomo-pathological changes in the mucous mem- 
brane of the pars prostatica around the caput gallinaginis were 
analogous to those which I described as found in the pars an- 
terior. The process essentially runs its course in the upper 
layers of the subepithelial connective tissue, and is a chronic 
inflammatory process with a first stage of small-cell infiltra- 
tion and connective-tissue proliferation, and a second stage in 
which cirrhotic connective tissue forms. 

The small-celled infiltration of the first stage is usually 
loose. In only one was it unusually dense, and the intensity of 
the inflammatory process then gave rise to miliary superficial 
foci of necrosis (Plate VII., Fig. 17, a, b). 

As a transition between the two stages there occurred in 
a few cases an outgrowth of the infiltrated connective tissue 
into small conical papillary excrescences, containing numer- 
ous newly formed vessels. 

The second stage remained superficial and did not lead to 
noticeable shrinking. 

The accompanying changes in the epithelium were: pro- 
liferation and desquamation of the cylindrical epithelium 
in the first stage, and conversion of the cylindrical epithe- 
lium into several layers of pavement epithelium in the second 
stage. 

The glands of the urethral mucous membrane, which are 
imbedded in the first stage in the subepithelial infiltration, 
take part in the inflammation in the shape of desquamative or 
desquamative purulent catarrh. In the second stage they are 
compressed and destroyed by the transformation of the infil- 
tration into cirrhotic connective tissue. 



•inger 



Plate VII. 



Fig. 17. 




~U W w w%^^^m&ri 



Fig. 18. 







^^^ v r 











— ■ --s^. 












Blenorrhcea of the Sexual Organs. 177 

The changes in the caput gallinaginis, ejaculatory ducts 
and prostatic glands merit special consideration. 

In the caput gallinaginis, as in the chronic inflammation of 
the urethra, the process runs its course in the well-known two 
stages of small-celled infiltration and the formation of callosi- 
ties. In one case the small-cell infiltration was unusually 
dense, and, as in the case of the urethra, miliary foci of necrosis 
were produced (Plate VII., Fig. 17, a, b). The natural result 
of this infiltration is enlargement of the caput gallinaginis. 
This enlargement was uniform in all cases except in one, in 
which it was nodular. The nodules were due to circumscribed 
foci of acute inflammatory infiltration by polynuclear leuco- 
cytes in connective tissue, which was in a condition of chronic 
inflammation. 

Corresponding to the two stages of small-celled infiltration 
and the formation of callosities, there was found in one series 
of cases catarrhal desquamation of the cylindrical epithelium, 
in another series conversion of the cylindrical into pavement 
epithelium. 

Much interest attached to the callosities observed upon 
the caput gallinaginis, and which consisted of cirrhotic con- 
nective tissue and pavement epithelium. One of these callosi- 
ties was located, like a depressed umbilication, upon the apex 
of the caput. In a second case it was situated on the side of 
the caput, entered deep into its tissues, and obliterated the 
opening of the ejaculatory duct. In two cases band-shaped 
depressed callosities passed over the highest point of the caput, 
obliterated both ejaculatory ducts and the utriculus, and di- 
vided the caput into two nodules. 

These callosities probably had different sources of origin. 

The one mentioned second, in which the microscope showed 
the presence of glandular tissue at the margin, was probably 
due to a follicular abscess in the acute stage of gonorrhoea. 
Such abscesses are found not infrequently, in acute posterior 
urethritis, as nodules of the size of a pea in the otherwise nor- 
mal tissue of the prostate. 

The other three umbilicated or band-shaped callosities 
can be explained most readily by superficial necrosis of the 
dense subepithelial infiltration, and this was actually observed 
in one case. 

In a number of cases the chronic inflammatory process 
12 



178 Blenorrhoea of the Sexual Organs. 

which has just been described is confined to the uppermost 
layers of the subepithelial connective tissue. 

In a second series of cases the process penetrates into the 
substance of the caput gallinaginis. This does not take place 
uniformly but only along-side the glands and their excretory 
ducts. The ejaculatory ducts may be affected in various ways 
by the inflammatory process. In the superficial forms only 
the mouth of the duct is affected by the infiltration, which com- 
presses or narrows it. I can hardly be mistaken in attributing 
the pains, of which many patients complain at the moment of 
ejaculation, to this compression of the opening of the ejacula- 
tory duct. 

The infiltration of the upper layers of the subepithelial 
connective tissue may also extend along the ejaculatory duct 
into the deeper parts. Disease of the wall of the duct then 
takes place in the well-known two stages. In the first stage 
the subepithelial connective tissue around the duct is sur- 
rounded by a small-celled infiltration which accompanies it 
through the caput gallinaginis into the prostate. If this in- 
filtration is converted, in the second stage, into cirrhotic con- 
nective tissue, the wall of the duct becomes rigid. 

The Avails of the ejaculatory duct, especially within the 
prostate, contain numerous diverticula, which empty into the 
duct in the direction of the ejaculated semen. In two cases I 
found these diverticula, deep in the prostate, filled with numer- 
ous spermatozoa. At the moment of ejaculation the semen 
cannot enter the diverticula, which empty into the duct at an 
acute angle to the direction of the current. This can only be 
effected by a return movement, by a regurgitation of the semen 
into the diverticula. This, in turn, will only happen if the force 
by which the semen is ejaculated is broken 03' constriction of 
the mouth of the ejaculatory duct or by rigidity of its walls. 
As a matter of fact, compression of the duct by subepithelial 
infiltration was found in one case, a callous condition of the 
walls of the duct in the second case. 

Semen which has entered the diverticula (during coitus or 
pollutions) may be expressed during subsequent micturition or 
defecation. Rigid ejaculatory ducts close the seminal vesicles 
imperfectly, and these findings thus explain the spermator- 
rhoea which is so frequent in chronic posterior urethritis. 

After cicatricial occlusion of the mouth of the ejaculatory 



Blenorrhoea of the Sexual Organs. 179 

duct, the latter is very much dilated and its diverticula are 
destroyed entirely or in part. The surrounding blood-vessels 
are very much dilated. I also found hemorrhages beneath the 
epithelium and even into the lumen of the ducts (Plate VII., 
Fig. 18). 

The infiltration of the subepithelial tissue may also extend 
periglandular around the glands within the prostate, but only 
in the superficial glands of the caput gallinaginis. The infil- 
tration is then localized particularly in those parts of the peri- 
glandular connective tissue which separate the individual tu- 
buli and project as villi into the lumen of the glands. These 
villi are infiltrated, elongated, lose their epithelium and ad- 
here to one another, so that the tubuli are occluded and a sec- 
tion of the gland exhibits an acinous appearance. 

Changes in the glandular epithelium are even more fre- 
quent, and may be divided into two classes. 

In one group microscopic examination shows dense filling 
of numerous glands and tubuli with proliferated and des- 
quamated epithelial cells (i.e., a purely desquamative catarrh) 
while other glands appear perfectly normal. These were the 
cases in which the prostatic secretion attracted attention by 
its amount, white color, and its consistence, but the micro- 
scope showed merely a striking increase of the epithelial ele- 
ments. 

In the second group, the lumen of numerous glands con- 
tained larger or smaller numbers of polynuclear leucocytes, in 
addition to desquamated epithelium (Plate VII., Fig. 19, c). 
This was a desquamative purulent catarrh of numerous 
prostatic glands. In these cases the secretion expressed from 
the prostate was abundant, milky-white, and in addition to 
the normal elements also contained numerous pus corpuscles. 

This desquamative or purulent catarrh of the prostatic 
glands is the undoubted cause of the symptoms of prostator- 
rhoea which are so frequent in chronic posterior urethritis. 

If we now make a resume of my anatomical investigations 
of chronic urethritis of the pars anterior and posterior, the 
following conclusions may be drawn: 

1. Chronic urethritis is a focal process, which runs its 
course as a chronic hyperplasia in the subepithelial connective 
tissue. Disease of the epithelium and glands is to be regarded 
in part as a complication, in part as a sequel. 



180 Blenorrhcea of the Sexual Organs, 

2. The foci of chronic blenorrhcea are localized preferably 
in the pendulous portion, the bulb, and the prostatic portion. 

3. The membranous portion is relatively immune to the 
chronic process. 

4. In a series of cases the foci of chronic inflammation in. 
the pars anterior and posterior are situated superficially in 
the mucous and the subepithelial connective tissue. 

5. In another series of cases these foci extend by continuity 
to the submucous tissue, in the pars anterior to the periure- 
thral and cavernous tissue, in the pars posterior to the pros- 
tate. 

6. This results in complicating* focal processes, chronic 
periurethritis and cavernitis in the pars anterior, prostatitis 
in the pars posterior. 

7. Hence arises the following- classification of chronic 
urethritis : 

I. Chronic anterior urethritis. 

a. Superficial anterior chronic urethritis. 

b. Deep anterior chronic urethritis {i.e., plus chronic peri- 
urethritis and cavernitis). 

II. Chronic posterior urethritis. 

a. Superficial chronic posterior urethritis. 

b. Deep chronic posterior urethritis (i.e., plus chronic 
prostatitis). 

As a matter of course, mixed forms are frequent, i.e., 
various foci in the pars anterior and posterior. 

Finally, the relation of gonococci to chronic urethritis is 
extremely, obscure. According to Bumm, relapses of acute 
urethritis are owing to the fact that the gonococci, in the last 
stage, push up from the deep parts through, the new-formed 
epithelium, and are compelled to more superficial growth in the 
uppermost epithelial layers. If no noxious influences intervene, 
the upper layers of epithelium, which contain the gonococci, 
are exfoliated and the process then appears to be ended. 

At this time the inflammatory process is disappearing- in 
the papillary stratum. But if any external morbific cause 
intervenes, the process underg-oes an exacerbation. Extrava- 
sation of lymph fluid and pus cells occurs, and this fissures the 
compact epithelial layer. Through these fissures the gono- 
cocci again penetrate to the papillary body, and produce irri- 
tation with acute suppuration, i.e., a relapse. The virulence 



Blenorrhcea of the Sexual Organs. 181 

of the gonococci is weakened by their long proliferation upon 
the same soil for many generations. As a proof we may men- 
tion the fact that chronic blenorrhcea is often conveyed as 
chronic, much more rarely as acute blenorrhcea. The fact that 
each succeeding relapse is milder and shorter also indicates 
that the irritation of the papillary body by the gonococci 
gradually diminishes. The first relapses will always termi- 
nate by the removal of the gonococci to the surface, but the 
virulence may finally be diminished to such an extent that the 
acute purulent symptoms on renewed invasion of the papillary 
body no longer suffice to carry the g-onococci to the surface. 
They will then remain in the papillary body, perhaps also in 
the follicles, and by their constant slight irritation give rise 
to the chronic proliferating processes in the mucous membrane. 

The conveyance of these enfeebled gonococci would explain 
the ab initio chronic infection in the female, and their prolifera- 
tion in the deep layers enables us to understand the fact that 
gonococci may or may not be found in the secretion, the clap 
shreds. 

But the chronic changes induced by the gonococci may 
develop further after the cocci have perished from any cause. 
This explains the fact that in certain chronic blenorrhceas we 
find the secretion and clap shreds but no gonococci. Perhaps 
certain changes which develop in the course of chronic blen- 
orrhcea — for example, the formation of connective tissue, which 
gradually becomes more and more fibrous — may be the direct 
cause of death of the gonococci, and therefore we often do not 
find the cocci, at least in the secretion, in old blenorrhceas 
which are complicated by stricture. But this is pure hypoth- 
esis, which, although plausible, is lacking in demonstration. 

Diagnosis and Differential Diagnosis. 

The diagnosis of chronic urethritis is evident from its symp- 
tomatology, and we will refer, therefore, merely to a few fac- 
tors which are especially important in diagnosis. 

The most frequent symptom from which the layman makes 
the diagnosis is the " good morning drop." 

But the presence of the drop is not a positive indication of 
chronic urethritis, nor does its absence exclude such a diagnosis. 

A secretion which is characteristic, whether it appears as 



1 82 BlenorrJioea of the Sexual Organs. 

a drop or as the co-ordinate clap threads, must contain two 
morphological constituents. In the first place the secretion 
must contain pus cells. A secretion composed of epithelium 
alone is not blenorrhagic, although it may persist for a long- 
time after the clap has run its course. 

The g-onococci are the second morphologically important 
element. We have described their characteristics and have 
also shown that they are not found constantly in chronic 
urethritis. 

In this regard there are three possibilities: The gonococci 
may be present in such numbers and arrangement that they 
permit a diagnosis at once. 

Or they are absent or present in such small numbers that 
doubt in the diagnosis is justified. More intense suppuration 
should then be produced by an injection of nitrate of silver or 
corrosive sublimate. This produces pus cells, enclosing char- 
acteristic cocci groups, and the diagnosis becomes clear. 

Finally there are cases in which no cocci are found, even 
after profuse suppuration is produced. Nevertheless these 
may be cases of chronic urethritis from which the gonococci 
have already disappeared. The demonstration of the purulent 
nature of the secretion, the history of one or more previous 
urethritides, examination with the urethrometer, the sound 
and endoscope, and the demonstration in this manner of a cir- 
cumscribed chronic inflammatory patch, permit a diagnosis 
to be made even here. 

If the question of the presence of blenorrhcea has been an- 
swered in the affirmative, then its acuteness is to be deter- 
mined by the finding of mucus in addition to pus or the absence 
of the former. Cases in which in addition to the pus (drop or 
clap threads) there is also mucous cloudiness in the urine, are 
the more recent, acute, less sharply circumscribed ones, in 
which, apart from the circumscribed chronic inflammation, 
there is also congestion and hypersecretion of larger areas of 
the mucous membrane. Those cases in which only clap shreds 
are found in otherwise clear urine are older affections, in which 
the process is sharply confined to one or a few diseased spots. 

With regard to all these questions the morning urine is 
particularly to be examined. 

To one point, however, I desire to call special attention. 
It has often been claimed that the test of the two beakers 



Blenorrhcea of the Sexual Organs. 183 

permits a differentiation between chronic anterior and pos- 
terior urethritis. This is not true. The test is based upon 
the fact that secretion formed in the pars posterior will re- 
gurgitate into the bladder and mingle with the urine. This 
does not happen, however, with the small quantity of tough 
secretion (clap shreds), even when formed in the pars pos- 
terior. These threads always appear in the first portion of 
urine. The second portion is clear, whether the case is an 
anterior or a posterior urethritis. In rare cases shreds may 
appear in the second portion under the following conditions : 

1. If the patient does not discharge sufficient urine in the 
first portion, it will be unable to wash away all the shreds and 
some will enter the second portion. 

2. After prolonged retention and when the desire to uri- 
nate has been experienced for some time, in cases of posterior 
urethritis. The pars prostatica will then be included physio- 
logically in the bladder in order to receive the urine, the 
secretion of the former will fall into the bladder, and will be 
demonstrable in the second portion of urine. 

3. When the shreds do not come from the mucous mem- 
brane but from the prostatic glands or their excretory ducts 
(Fuerbringer's hooks). These are expressed during the 
evacuation of the last drops of urine. 

In this connection it is to be noted that all secretions which 
originate in canals that empty into the side of the urethra 
(prostate, seminal vesicles) are discharged with the last drops 
of urine and are found accordingly in the second portion. 

We next consider the question of localization and the nature 
of the changes. 

The symptoms which furnish data concerning the situation 
of the process have already been considered. 

We first examine the second portion of the morning urine 
for mucous cloudiness and comma-shaped shreds from the 
prostate, phenomena that favor the diagnosis of chronic pos- 
terior urethritis. 

If this examination gives negative results, irrigation of 
the pars anterior by means of an elastic catheter introduced 
as far as the bulb will furnish information concerning the 
derivation of the shreds. If the urine passed after irrigation 
is free from shreds, the latter are derived from the pars 
anterior alone; if it contains shreds, they are due to posterior 
urethritis. 



1 84 BlenorrJicea of the Sexual Organs. 

Inquiry is then made for all those symptoms which usually 
accompany this form. Without putting- any leading questions 
we often obtain important positive statements concerning 
prostatorrhoea, disturbances in micturition and the sexual 
functions. 

In addition to data obtained in this way, instrumental ex- 
amination with the sound, urethrometer, and endoscope will 
furnish information concerning 1 the location and nature of the 
changes. 

When shall instrumental examination of the urethra be 
made ? 

According" to my experience not until the process has really 
become localized. So long as mucous cloudiness of the urine 
is still present, the instrumental exploration should not be 
practised. We must first combat the congestive condition 
which causes the secretion. If instrumental examinations are 
made at a time when the congestion and mucous secretion 
are still present, the increased inflammation is apt to convert 
the mucous secretion into a purulent one, which may last for 
weeks. More or less numerous gonococci are then usually 
found in the pus. 

Exploration with the urethrometer and sound is the milder 
of the modes of examination, and is therefore to be emplo3 r ed 
first. I agree entirely with Tarnowsky that the endoscope is 
to be used only in those patients who have been examined 
several times with the sound and have become accustomed to 
the irritation. The latter often furnishes us with sufficient 
information concerning the site of the affection. 

The endoscope is always absolutely indicated when a chronic 
localized blenorrhoea resists instrumental measures, and does 
not recover despite local treatment. Despite the use of 
the endoscope, examination with the urethrometer should 
never be neglected. It alone gives us positive information 
concerning the diminution of dilatability, and thus concerning 
the density and depth of the infiltration and the degree of 
conversion into fibrillary connective tissue. 

Examinations with the endoscope should be made only by 
the specialist, as it may readily produce injury to the canal. 
Larger calibres are always to be recommended, and I never 
employ less than 22 Charriere. If the meatus is narrower I 
prefer to make the slight operation of division rather than to 



Blenorrhcea of the Sexual Organs. 185 

deceive myself and the patient with the uncertain results of 
examination with 18 or even 16 Charriere. Careful examina- 
tion usually furnishes valuable information, and the discovery 
of the infrequent polypi can only be made with the endoscope. 

From a differential diagnostic stand-point it must be re- 
membered that not every drop which is squeezed out of the 
meatus is blenorrhagic pus. We must first ask concerning 
the appearance of the drop. The patient tells us not infre- 
quently that the drop is as clear as water and is squeezed out 
in the morning-, but agglutinates the meatus during- the day. 
We then have to deal with a simple urorrhcea. It is a well- 
known fact that in erections, especially if protracted and vig- 
orous, a drop of clear, stringy, sticky mucus escapes from the 
orifice (urorrhcea ex libidine of Fuerbringer, " suintement 
muceux" of Diday). This hypersecretion of a normal urethral 
mucus becomes permanent in individuals whose urethra is in 
an irritated condition from a previous blenorrhcea, habitual 
onanism or long-continued sexual excesses. This mucus con- 
tains very scanty formed elements, mucous corpuscles and 
epithelium, no pus cells, not infrequently a small number of 
various cocci and bacteria, but no gonococci. 

Caution is necessary even if the mucus is colored and milky. 
The urorrhcea just described, especially if it follows an acute 
urethritis which has run its course, not infrequently makes 
the patient and physician believe in the continuance of the 
urethritis, and the necessity of treatment with injections, 
bougies, etc. The following state of affairs is then apt to 
develop : 

The originally clear secretion becomes grayish, opalescent, 
then milky white. The cellular elements have increased in 
number, but consist only of epithelium, usually large rhombic 
pavement epithelium, upon and between which are numerous 
micro-organisms, especially a short, narrow bacillus, arranged 
in chains (Plate IV., Fig. 11). Their number is so large that 
I interpret the abundant desquamation of the epithelium cov- 
ered by them as an irritative phenomenon, and incline to the 
opinion that the micro organisms enter the urethra during the 
injections and instrumental measures adopted against the 
urorrhcea, or that they enter from the praeputial sac. They 
proliferate upon the soil which has been alkalinized and so 
prepared by the urorrhcea, and then give rise to the increased 
desquamation as a slight irritative phenomenon. 



i86 



Blenorrkcea of the Sexual Organs, 



This form of urorrhcea heals rapidly after a few injections 
of a weak solution of corrosive sublimate (1:4000). 

The same form may also occur in connection with chronic 
urethritis. 

The prostatorrhcea described by us occurs, although rarely, 
either after a cured acute posterior urethritis, especially if it 
was complicated by epididymitis, or in masturbators ; it occurs 
alone or combined with sexual neurasthenia. Its demonstration, 
therefore, is not an absolute sign of chronic posterior ure- 
thritis. The prostatorrhcea, which is usually manifested only 




Fig. 26. 

during- defecation, must be associated with the symptoms of 
chronic urethritis, especially clap shreds containing pus cor- 
puscles. 

Finally, there is a rare form of prostatorrhcea which com 
sists of increased production and discharge of normal prostatic 
secretion. Unlike the thick, muco-purulent secretion of pros- 
tatorrhcea due to chronic prostatitis, this is thin and milky, 
and is brought to light by pressure on the prostate per anum 
or by examination of the urethra with sounds of the highest 
possible calibre. 

We have to consider one phenomenon, viz., phosphaturia, 



Blenorrhcea of the Sexual Organs, 187 

ignorance of which is apt to cause great confusion. We not 
infrequently observe the following" condition in patients under 
treatment for chronic urethritis. At one time or another 
when the patient evacuates his urine in two portions, we find 
the entire urine of a milky white color, with a shade of green. 
If the urine is allowed to stand, a white granular or finely 
flocculent sediment is rapidly precipitated. This sediment not 
infrequently leads to the diagnosis of vesical catarrh. On ex- 
amination with the microscope (Fig. 26) it is found to consist 
of phosphate and carbonate of lime, the former in amorphous, 
finely granular masses, the latter in wedge-shaped c^stals, 
which are joined together into masses of sheaves and rosette 
shapes. The urine is feebly acid, neutral or feebly alkaline, 
thus increasing the suspicion of cystitis. But the diagnosis 
becomes clear, even without microscopic examination, on 
adding a few drops of acetic acid to the turbid urine, which 
clears it up. If carbonate of lime is present bubbles of car- 
bonic acid form, but the phosphate of lime is dissolved without 
effervescence. This condition is explained by the insufficient 
acidity of the urine, which does not keep the constituents 
mentioned in solution. 

Phosphaturia is observed under the following conditions : 
1. In acute and chronic urethritis, when the patient keeps too 
strict a diet and abstains for a long time from acid or salted 
food. 2. In chronic urethritis posterior and neurasthenia, be- 
longing with polyuria to the sjanptomatology of neurasthenia 
as a secretory neurosis. 3. In acute and chronic urethritis 
when the physician recommends alkaline mineral waters, es- 
pecially Giesshuebler and Preblauer water, in addition to strict 
diet, as is unfortunately often done. 

Phosphaturia not infrequently runs an entirely latent 
course ; in other cases, especially when phosphate of lime pre- 
dominates in the sediment, the crystals cause burning during 
micturition and vesical tenesmus. 

The condition is usually not permanent ; cloudy urine alter- 
nates with clear urine. The morning urine is usually clear, 
the first urine passed several hours after meals is cloudy. 

Ingestion of vegetable acids, also hydrochloric, acetic, or 
phosphoric acid, generally causes rapid disappearance of the 
cloudiness. Cantani recommends: 



1 88 BlenorrJicea of the Sexual Organs. 

$ Acid, lactic, 3 j. 

Aq. fontis, § vj. 

Aq. menthse, 3 ij. 

S. 1 j in J glass of soda water every two hours. 

The cloudiness of phosphaturia does not interfere with the 
diagnosis of chronic blenorrhcea, because the opacity due to 
the presence of the lime salts disappears on the addition of a 
few drops of acetic acid. The urine either becomes perfectly 
clear and shows the shreds of chronic urethritis, or a mucous 
cloudiness, in the more recent cases, remains, in which the 
shreds float. 

Prognosis. 

A cautious prognosis is even more necessary in chronic than 
in acute urethritis. 

The length of time in which the blenorrhcea will recover 
can never be foretold, nor can we even tell with certainty 
whether the disease will be cured at all. With the more ra- 
tional basis for therapeutics the possibility of cure becomes 
greater, and the physician who is versed in the advances of 
recent therapeutics will cure a larger number of cases than 
one whose entire repertory consists of a clap syringe and 
thirty or forty prescriptions for endlessly varying injections. 

But a certain proportion of chronic blenorrhceas remain 
intractable to all treatment. In the first place, because many 
patients do not regard the question seriously enough and be- 
cause they are lacking in a quality which cannot be supplied 
by the apothecary, viz., patience. Others are incurable be 
cause they are treated too much, are really maltreated. 

There are two factors which impair the prognosis of chronic 
blenorrhcea. One series of cases do not become agrgavated, 
even though they may not be cured, but another series grow 
worse with the lapse of years, and present complications and 
changes which become more distinct with the duration of the 
disease — stricture in anterior chronic urethritis, prostator- 
rhcea and sexual neurasthenia in posterior urethritis. 

In general the prognosis is more favorable in recent cases, 
less favorable in old, inveterate cases. It is more favorable 
in anterior than in posterior urethritis, because the former is 



Blenorrhoea of the Sexual Organs. 189 

more accessible to treatment, and stricture is a more easily 
treated complication than neurasthenia. The prognosis is 
also more favorable in those cases which have resulted from 
neglect of acute urethritis, more unfavorable in those in which 
the acute blenorrhcea had received various modes of treat- 
ment, and most unfavorable when the chronic urethritis itself 
has been the subject of varied, but usually unsystematic, 
therapeutic trials. 

Finally, the prognosis is relatively favorable in those cases 
which, despite their long continuance, present neither stricture 
nor neurasthenic symptoms. 

Treatment. 

The same confusion is found here as in the treatment of 
acute urethritis. 

The older physicians believed in the syphilitic character of 
chronic urethritis even more firmly than in that of the acute 
form, and the former was therefore treated with anti-syphil- 
itic remedies if it did not yield within a certain length of time 
to copaiba, ptisans, and baths. We read in Fabre (1773): 
"Apres tous ces remedes, on saura a quoi s ? en tenir sur le carac- 
tere de la maladie, et s'il faut en venir au grand remede pour 
la guerir, suppose qu'elle ne le soit pas." 

On the whole chronic urethritis was neglected more often 
than at present, and only one sequel, viz., stricture, received 
early treatment. Alexander Trajanus Petronius, of Castile, 
recommended cleansing the urethra with a wax candle or 
some similar instrument. The use of caustics in powder and 
ointments was also recommended, under the supposition that 
the stricture resulted from a caruncle or projecting spongy 
growth. Wiseman, physician to Charles II., inserted a tube 
into the urethra as far as the stricture, and there applied 
a caustic, viz., red precipitate. Caustics were used so vigor- 
ously at that time that Astruc (1754) made a decided protest, 
and mechanical dilating apparatus was employed thereafter. 
Le Dran recommended catgut, Daran bougies, which were used 
by Fabre (1773), Kuehn (1785) and Hunter (1786). B. Bell 
pointed out the circumscribed site of chronic blenorrhoea and 
recommended bougies, which must be thick, because they act, 
in the main, mechanically by exerting pressure. Local as- 



190 Blenorrhcea of the Sexual Organs. 

tringents were also used. In obstinate cases Bell recommended 
that the bougies be smeared with turpentine or red precipitate 
ointment. Lallemand devised his porte-caustique in order to 
make localized cauterizations in the urethra and Merrier con- 
structed a similar instrument. Both are short, curved cathe- 
ters with a lateral fenestra, behind which is the caustic, which 
is at first concealed but is exposed by a twist. 

Schuster (1870) recommended bougies of tannin and glyc- 
erine, which are introduced into the urethra, where they melt 
and act as astringents. Regnal and Lorey recommended 
gelatine bougies containing various solutions. Chiene (1876) 
injected into the urethra a paste of kaolin, oil and water. 
Walicki (1876) described an apparatus like a glove stretcher 
which is introduced, while closed, into the urethra, then 
opened, and used for blowing in powders. Zeissl made rods of 
kaolin and glycerine, which he inserted into the canal. Mas- 
urel injected a saturated solution of tincture of iodine in water. 
In obstinate cases of chronic urethritis Harrison (1885) even 
went so far as to draw off the urine by incising the membra- 
nous portion, and passing a silver cannula into the bladder. 

All the injections to which we have referred in discussing 
acute urethritis have also been given in the chronic form, as 
well as the most varied internal remedies. 

The local remedies and methods mentioned have all been 
recommended on a purely empirical basis, without any indi- 
cation or accurate notion of their action. As they are intro- 
duced blindly into the urethra or after a preliminary ex- 
ploration with the sound, it is never certain that they come 
in contact with the diseased surface. But they always reach 
healthy portions of the urethra and cause irritation. The 
action of the inert materials, such as kaolin, is purely mechani- 
cal and irritating, and even the astringents possess merely a 
superficial effect. 

Desormeaux had obtained some therapeutic benefits in 
cases in which he found a circumscribed lesion in the urethra, 
by fixing the endoscope in the canal, removing the illuminat- 
ing apparatus, and applying medicaments through the tube. 
Or he inserted a lateral opening in the endoscopic tube for the 
introduction of a tampon, brush, and caustic -holder, and thus 
manipulated under the control of the eye. Tarnowsky also 
practiced treatment through the endoscope, and warmly rec- 



Blenorrhaza of the Sexual Organs. 191 

ommencls it. As the endoscope was improved, local manipu- 
lations were facilitated. Gruenfeld, Gschirhakl and Auspitz 
adopted endoscopic treatment, and Gruenfeld regarded it as 
the only rational method. But this is not true. Apart from 
the fact that the introduction of the instrument irritates the 
mucous membrane, and is apt to produce catarrhal symptoms 
on frequent application, all the manipulations performed in 
the endoscope, cauterizations as well as brushings, are directed 
only to the surface of the mucous membrane, and cannot affect 
infiltrations which are situated deep in the mucosa and in the 
submucous tissue. Just as in the treatment of trachoma the 
brushing- with solutions of nitrate of silver and cauterization 
with copper sulphate in substance may cause disappearance 
of the granulations, but cannot prevent the formation of cica- 
trices, so the same manipulations in the endoscope may heal 
erosions and granulations, while deep infiltrations which may 
be present will run their progressive course and terminate in 
stricture. 

Hence we also require methods which have a deeper action. 
B. Bell had recognized that the use of bougies depends chiefly 
on their pressure effects. But Otis was the first who, with the 
proper appreciation of the varying diameters of the different 
parts of the urethra, employed pressure in its full measure. 
He taught us how to measure the diameter of the normal 
urethra by means of the urethrometer, an instrument which 
also informs us concerning those beginning stenoses whose 
calibre is still greater than that of the meatus. Previous to 
Otis we were satisfied with passing those sounds which would 
just pass through the orifice. It is clear, however, that such 
a sound, for example, No. 24 Charriere, could show nothing if a 
part of the bulb is narrowed from 45 Charriere to 36, and 
therapeutic action would also be imperfect. It is clear that a 
portion of the canal which originally had a calibre No. 40, 
could only be regarded as normal when it is again stretched 
to No. 40. This dilatation was hitherto prevented by the nar- 
rowness of the orifice. To the circumstance that strictures 
ceased to be treated when they reached the width of the ex- 
ternal meatus is due the fact that the majority are merely 
improved, not cured, and that they relapse so rapidly. 

Otis formulated the correct principle that the canal must 
be restored to its original calibre, and therefore employed 



192 



BlenorrJicea of the Sexual Organs. 



sounds of large size, up to 30 or more. The resistance of the 
meatus to such a sound is removed by splitting- it in the direc- 
tion towards the frenu- 
lum. The little opera- 
tion is a trivial one and 
heals rapidly. By suc- 
cessive increase of the 
size of the sounds, Otis 
heals beginning stric- 
tures as heretofore, ex- 
cept that he brings the 
canal to its normal di- 
mensions or even be- 
yond. 

Oberlaender (1887) 
and v. Planner were not 
satisfied with this grad- 
ual dilatation, but in- 
dependently devised di- 
lators. These possess 
straight or slightly 
curved blades of steel, 
which can be separated 
uniformly by the action 
of a screw, and an in- 
dex shows the degree 
of dilatation. A lining 
of rubber prevents nip- 
ping of the folds of the 
mucous mem brane. 
The object of these 
dilators is not alone to 
act by pressure but also 
to tear the chronic in- 
filtration by the forced 
dilatation. Oberlaen- 
der imagines that from 
these rents an acute 
inflammation will start 
and will aid in the absorption of the chronic infiltration. 

Otis (1880) devised a dilating urethrotome (Fig. 28) which 




Fig. 27. 



Blenorrhoea of the Sexual Organs. 



193 



closely resembles Oberlae rider's, except that the upper blade 
carries a concealed knife, which is exposed by means of a 
spring". Forced dilatation is thus united with internal ure- 
throtomy when the resisting- tissue will not yield. 

Starting from the theoretically correct and certainly prac- 
ticable idea of the union of pressure and astringents, i.e., of 
deep and superficial action, Unna (1884) devised his ointment 
sounds. He covers his sounds with a mixture of: 



B 01. cacao, 
Cerae flavse, . 
Argent, nitrat., 
Bals. peruvian., 

^ Paraffini, 
Bals. copaiv., 
Argent, nitrat., 
Yaselin., 

3 Gelatin alb., . 
Aq. destil., 
Glycerin., 
Vaselin., 
Argent, nitrat., 



• !Uj. 

. 3 ss. 

. gr. xv. 

. 3 ss. 

. 3 iij- 

. gr. xxx. 

. gr. xv. 

s. ad 3 iij. 

. Ji. 

• 5 iij. 

. 3 ss. 

. 3v. 



This mass, which is solid at ordinary temperatures, is 
liquefied in a lukewarm water bath, the sounds -dipped in it 
and then hung up at the temperature of the room. 

The warmth of the urethra melts the mass, and the nitrate 
of silver contained in it then acts upon the mucous membrane. 
Instead of the ordinary cylindrical sounds Casper uses sounds 
with six grooves, which terminate 5 cm. from the tip, and are 
intended for the reception of the ointment. In this way he 
avoids the passage of the ointment into the bladder. Appel 
and v. Planner, although they advocate this plan, observed 
irritative symptoms on the part of the urethra and bladder. 
Despite the good results obtained in many cases by this mode 
of treatment, I oppose it for the reason that the entire ureth- 
ral mucous membrane is brought in contact with a strongly 
irritating 1 per cent, nitrate of silver ointment, and hence the 
healthy mucous membrane is irritated and hypersecretion 
induced. 

13 



194 Blenorrhcea of the Sexual Organs. 

I will now analyze those methods which I can recommend 
as the most useful, within the bounds of certain indications. 

Apart from the localization we have recognized two forms 
of chronic urethritis : 

1. The more recent forms in which, in addition to circum- 
scribed foci, larger surfaces of the mucous membrane appear 
to suffer from congestion or passive hypersemia. They mani- 
fest themselves by increased production of mucus, i.e., by a 
cloudy, mucous urine associated with clap shreds. 

2. Circumscribed, older forms, in which the changes, a, are 
either superficial, in the mucosa, 

Or, b, are also situated in the submucous tissue. In ac- 
cordance with this classification I will formulate a few 
sharply defined indications. 

I. In the first form we must first combat the concomitant 
catarrhal symptoms, by applying dilute, feeble astringent 
solutions to the catarrhal portions, so that only the deeper 
foci remain. 

II. In variety a of the second form we must cure the cir- 
cumscribed foci in the mucosa by making local applications of 
stronger astringents and caustics. 

In variety b of the second form we must act upon the sub- 
mucosa by pressure and absorbents, in addition to the previ- 
ously mentioned indications. 

In all three cases, however, we must ascertain the locali- 
zation in order to apply the remedies actually upon all dis- 
eased parts. 

When to begin treatment is an important question. If we 
have to deal with a neglected chronic urethritis which has not 
been treated for a long time, we must begin at once. 

Our plan must be entirely different if the patient, up to 
the time that he came under our care, has been treated for a 
long time by the various astringents, caustic and instrumen- 
tal procedures. 

In these cases I cannot advise too strongly against the 
continuance of the treatment. It is urgently necessary to per- 
mit a rest in local treatment. We must not forget that pro- 
longed treatment, especially if carried out vigorously and with 
active remedies, is apt to cause irritation of healthy portions 
of the urethra, whose secretion aggravates the symptoms. 
If we wish to know the real condition, the irritative symp- 



BlenorrJioea of the Sexual Organs. 195 

toms must be made to disappear by discontinuing* the irrita- 
tion. 

I desist, therefore, for several weeks from all local treat- 
ment, and, in order that I may appear to be doing something-, 
give internally a little sandal- wood oil, cubebs, or kawa-kawa. 
If the proper hygienic-dietetic rules have also been carried 
out, the irritative symptoms, which may have been present, 
will disappear, and in three or four weeks we have the uncom- 
plicated condition before us. 

Finally, it goes without saying* that uncomplicated, chronic 
urethritis alone may be the subject of local treatment. 

I. If we proceed according* to these principles, and have to 
deal, as the symptoms prove (I do not recommend the sound 
and endoscope for the more recent forms of chronic urethritis), 
with a recent chronic urethritis of the pars anterior, we may 
inject diluted astring*ents with the g-onorrhcea syring*e. It is 
better, however, to inject under stronger pressure, with the 
aid of my apparatus. We prescribe : 

I* Argent, nitrat., gr. iss. 

Aq. clestil., 3 iij. 

^ Cupri sulph., gr. iss. 

Aq. destil., 3 iij. 

which is injected once a day in the evening. My favorite plan 
in these cases is to perform irrigation of the pars anterior 
ever}^ second day, while the patient himself uses the injections 
two to three times a day. After the patient has urinated I 
pass to the bulb with a not too large elastic catheter and in- 
ject one of the usual solutions from behind forwards through 
the entire pars anterior. During the injection I occasionally 
compress the externa] orifice and thus secure complete dis- 
tention of the pars anterior and entrance of the drug into the 
folds and openings of the follicles. But the process is rarely 
confined to the pars anterior. The S3 T mptoms or the history 
of a previous epididymitis or acute posterior urethritis 
often indicates with certainty, or at least with great proba- 
bility, that the catarrhal disease extends to the pars posterior. 
In such cases the entire urethra must be washed with the astrin- 
gents. I prefer to do this according to Diday's method rather 



196 Blenorrhoea of the Sexual Organs, 

than with Ultzmann's irrigation catheter, inasmuch as the 
metallic catheter always irritates more strongly, and I regard 
the unirritating application of the remedies as very important. 
With irrigations every second day — every third day if the re- 
action is marked — the mucous secretion disappears, and the 
urine contains only flocculi. We now have the second form 
of chronic urethritis before us. After the urine has cleared 
up, it is advisable to permit a short interval to elapse before 
proceeding to the treatment of the localized infiltration in the 
mucous membrane. 

II. If the case is one of the older forms — clap shreds in the 
clear morning urine — we must localize both the situation as 
well as the depth of the affection, by the aid of the sound, ure- 
thrometer and endoscope. 

We will first assume that we are dealing with a superficial 




Fig. 29. 

chronic urethritis, localized in the mucosa, without beginning 
stricture or implication of the prostate. 

It is then our object to apply the more concentrated as- 
tringents upon the site of disease and upon this alone. 

If the instrumental examination has shown that the disease 
is confined to the pars anterior the astringents may be ap- 
plied most simply by the aid of Ultzmann's brush apparatus 
(Fig. 29). This consists of a narrow hard-rubber endoscope, 
usually Charriere 16 to 18, whose introduction, with a conduc- 
tor, into the anterior urethra causes but little irritation. The 
astringent solution is applied through this endoscope by means 
of a brush whose handle can be moved in such a way that 
the hair of the brush alone projects beyond the rim of the endo- 
scope. We may use nitrate of silver 1 : 30 to 50, or sulphate of 
copper, which I recommend particularly, in the same strength. 

Cases of isolated foci in the pars bulbosa are rare. The 



Blenorrhoea of the Sexual Organs. 



197 



process extends more frequently into the membranous portion; 
often there is also a second focus in the prostatica portion, or 
the latter alone is demonstrable. 

In these cases we may use gelatine suppositories prepared 



according- to the following formula : 



$ Iodoform, 

Tannin, 

Zinc, sulph., 

Cupri sulph., 

Argent, nitrat. 
Gelatinae albse q. s. f. supposit. 
inches x I inch. 



. gr.vij. 

• gr. iij. 
. gr. iij. 
. gr. iss. 
. gr.!. 
urethralia conica No. x. 



aa 2 



These are oiled and introduced by the patient, in the recum- 
bent posture, as far as he is able, with the fingers on the peri- 
neum, to follow the urethra. The patient then fixes the bougie 
by the pressure of the fingers, it melts and thus produces its 
effect. But this mode of application is uncertain. The lique- 
fied mass sometimes escapes externally and irritates healthy 
portions of the mucous membrane. 

Ultzmann recommends bougies of butter of cacao: 

$ Alumin. crudi, gr. xv. 

Tannin, pulv., gr. v.-viij. 

Zinci sulph., gr. ij.-v. 

Argent, nitrat., gr. iss. 

Butyr. cacao q. s. f. supposit. urethralia brevia No. V. 

These are inserted into the pars prostatica by the aid of 
Dittel's te porte remede " (Fig. 30). This instrument consists 
of a catheter open at the vesical end, and whose opening is 
closed by an olive tip situated on a conducting rod, furnished 
with a spring. The catheter, closed by the olive tip, is passed 
into the urethra as far as the pars prostatica, the olive and con- 
ducting rod withdrawn, and one of the previously mentioned 
bougies inserted into the catheter. This is then shoved for- 
wards by means of the tip and deposited in the pars prostatica. 

In these cases I prefer to make local injections of a few 
drops of fluid by means of Guyon's syringe or Ultzmann's 
catheter syringe. 

After the Pravaz syringe of Ultzmann's apparatus is filled 
a few drops are first deposited in the pars prostatica, and, if 



198 Blenorrhcea of the Sexual Organs. 

necessary, a few drops may also be applied, during with- 
drawal, to the membranous portion. I use 0.1-10 per cent, 
solutions of silver and copper, beginning with the weaker ones 
and increasing the strength gradually as the irritation pro- 
duced by them begins to diminish. The instrument should be 
lubricated with glycerine, because oil, when carried into the 
urethra, forms a layer which is permeable with difficulty by 
the watery solutions, and therefore weakens their action. 

The introduction of lanolin ointments is more serviceable 
than that of watery solutions. Tommasoli (1887) has devised 
a simple syringe (Fig. 31) for their introduction, and many 
trials, some associated with him, have led me to recognize the 
advantages, of this method. The syringe consists of a short 
catheter, No. 16 to 18 Charriere, with a moderately large open- 
ing at the vesical end. Within the catheter is a piston on a 
somewhat flexible rod, which carries marks, that correspond 
to a decigramme. The ointment is placed in an ordinary clap 
syringe and then injected into the open catheter syringe from 
behind. The following formula is used : 

^ Argent, nitrat. or cupri sulph. or creolin., gr. xv- 3 i. 

Lanolin, 3 iij. 

01. olivar., 3 iss. 

The filled and slightly lubricated syringe is now introduced 
into the pars prostatica and one decigramme deposited. Dur- 
ing withdrawal, the ointment may also be deposited in the 
membranous portion and bulb. 

The lanolin ointments possess the advantage of adhering 
intimately to the mucous membrane. If fluids, gelatine or 
cacao-butter bougies are introduced, they are washed out of 
the urethra by the first micturition. On the other hand, the 
contracting urethral walls compress the lanolin ointment after 
the injection and press it into the mucous membrane. Mictu- 
rition evacuates only small particles of the ointment, which 
are found in the urine even thirty-six hours after injection. 
Even pollutions do not remove all the ointment from the 
urethra. It therefore forms a real urethral bandage, and its 
protracted action and gradual absorption have a more favor- 
able effect than the ephemerally acting solutions. In addition, 
as Professor Liebreich kindly informs me, lanolin is an aseptic 
substance. 



Blenorrhcea of the Sexual Organs. 



99 






Fig. 30. 



Fig. 31. 



200 Blenorrhcea of the Sextial Organs. 

B. Finalty, we must consider the last form of chronic 
urethritis, in which the process extends to the submucous tis- 
sues, and produces either diminished dilatability or hyper- 
trophy of the caput gallinaginis with secondary prostator- 
rhcea and neurasthenia. 

One of the most sovereign remedies is pressure. We here 
use sounds of large calibre, beginning with those which barely 
pass the stricture and gradually increasing to 28 or 30 Char- 
riere, perhaps after preliminary incision of the external orifice. 
If the infiltration is very dense and extends to a considerable 
depth or is undergoing fibrillary changes — in which event the 
urethrometer shows considerable diminution of dilatability 
and the resistance to further separation of the instrument is 
marked — the treatment with sounds often proves insufficient. 

In such cases we may resort to Oberlaender's dilator. 
The instrument, well lubricated with glycerin or vaselin, is first 
introduced as far as it can be without pain, and dilatation is 
performed without the employment of violence. At the end 
of a few minutes the dilatation is increased one or two num- 
bers. Too rapid dilatation is inadvisable. When the in- 
filtration yields blood will escape either during or after the 
dilatation. The dilatations are repeated at intervals of eight 
to ten days, the amount being increased at each sitting. 

Otis' dilating urethratome is only indicated when the dilata- 
tion is resisted by very firm connective tissue. 

When this form is located in the pars prostatica and the 
caput gallinaginis is hypertrophied, no stricture can be demon- 
strated, nevertheless the use of large sounds is often attended 
with admirable results. In wide strictures the mucous mem- 
brane of their surface and surrounding parts is usually the site 
of chronic inflammation. In addition to sounds we may, ac- 
cordingly, also use astringents in the previously mentioned 
manner, applying either aqueous solutions or lanolin ointments 
to the diseased parts. We particularly recommend the fol- 
lowing : 

J£ Potass, iodid., ... . . 3 iss. 



Iodin. puri, . 
Lanolin, 
01. oilvar., . 
M. Exactissime 



gr. xv. 
liij. 

3 iss. 



Blenorrhcea of the Sexual Organs. 



20 1 



This ointment is absorbed well 
and has often stood me in good 
stead in old foci in the bulb as 
well as in the caput gallinaginis. 
In these cases we first introduce 
the oiled sound, keep it in situ 
for five to fifteen minutes, and 
then, by means of Tommasoli's 
syringe, deposit the above oint- 
ment in the pars prostatica, and, 
if necessary, in the membranous 
portion. In performing Ober- 
laender's dilatation the injections 
are used one to three days after 
the dilatation. 

Winternitz's psychrophor, the 
cooling sound (Fig. 32), is admir- 
ably adapted for cases of isolated 
disease of the pars posterior with 
hypertrophy of the caput gallin- 
aginis, prostatorrhoea, and mic- 
turition and defecation sperma- 
torrhoea. The instrument consists 
of a completely closed catheter, 
of 20 to 24 calibre, which is divided 
internally into two compartments 
by a longitudinal septum. These 
communicate anteriorly at the tip 
(f the catheter and are connected 
externally, at the fork-shaped 
end, with two tubes. If one of 
these tubes is dipped into an ele- 
vated vessel of water and suction 
made upon the other, the water 
will run through the catheter (to 



communicates its tem- 
and flow into a lower 
a syphon action. The 



which it 

perature 

vessel by 

catheter is inserted as far as the 

pars prostatica — its introduction 

into the bladder ma}' give rise to 

irritative symptoms — and water 



r 




202 Blenorrhoea of the Sexual Organs. 

is allowed to flow through for about fifteen minutes daity, at 
first at the temperature of the room, but gradually cooled, 
in subsequent applications, to 10° C. This may be followed 
by the injection of a few drops of a strong solution (3 to 5 per 
cent.) of nitrate of silver, or of a nitrate of silver or iodine- 
lanoline ointment into the pars prostatica. 

If the patient has been examined with the endoscope and 
tolerates this manipulation well, the results of treatment may 
be controlled in this way every two to four weeks, and, at the 
same time, the locus morbi cauterized with sulphate of copper 
or the solid stick. 

The relatively rare polypi, which can only be diagnosed 
with the endoscope and whose connection with chronic ure- 
thritis is questionable, require surgical treatment with forceps, 
with snares and scissors. The operation may be performed 
through the endoscope. 

And now a few general recommendations concerning all 
these procedures. 

With the exception of Diday's irrigation, which is per- 
formed when the bladder is moderately full, all these manipu- 
lations should be preceded by evacuation of the bladder. 

All local measures are followed by a reaction, greater after 
injections, slighter after the applications of sounds. When 
the manipulation is confined to the pars anterior the reaction 
is manifested by suppuration; when the pars posterior is also 
implicated, by vesical tenesmus. 

These symptoms follow the manipulation forthwith, and 
rapidly reach their acme, after which they soon subside. The 
reaction is usually ended in six to twelve hours. The tenes- 
mus, wmich is often distressing after the injection, soon forces 
the patient to urinate. This is relieved by the preliminary in- 
troduction of a morphine or belladonna suppository. It is well 
to direct the patient not to urinate for several hours after the 
injection or sounding. 

The repetition of the manipulation, application of the 
sounds, irrigation, or injection, is made every three or four 
days. It should never be performed earlier than twenty-four 
hours after the cessation of the reaction occasioned by the 
previous manipulation. It is also advisable not to treat con- 
tinuously for too long a time, but to desist for one to two weeks 
after a period of several weeks' treatment. 

The urethra becomes dulled against all irritants and their 



Blenorrhcea of the Sexual Organs. 203 

action becomes more distinct after a rest. In many cases 
sounding- for beginning- stricture is no exception to this rule, 
but we may often carry on the treatment continuously. 

The treatment is to be kept up until complete recovery, 
i.e., until all morbid symptoms have disappeared. But it should 
not be forgotten that clap shreds consisting of epithelium and 
desquamations from xerotic patches are trifling matters and 
not to be relieved, and that long protracted treatment itself 
may cause hypersecretion and proliferation of the mucous 
membrane, i.e., cloudiness of and flocculi in the urine. In other 
words the effects of the remedies only appear distinctly after 
the cessation of treatment. 

We should always secure regular evacuations from the 
bowels. Constipation and hemorrhoidal difficulties cause 
delay in recovery and exacerbations. 

Frequent lukewarm sitz baths, full baths and sea-bathing 
act as adjuvants. 

The strict injunctions regarding food and drink which are 
given in acute urethritis are unnecessary; the patient must 
simply avoid indigestible, constipating food and an excess of 
alcoholics. 

Moderate exercise is permissible; forced movements, espe- 
cially riding, are to be eschewed. 

The question of coitus is important. When performed with 
a preventative, infection of the partner is not easily possible. 
To forbid coitus in chronic gonorrhoea is impracticable, because 
the patient will not obey instructions. I therefore consider it 
advisable not to destroy the patient's candor, but to remain 
en rapport with him on this point. Coitus may be allowed at 
intervals of three to four weeks, but his attention may be called 
to the fact that a coincidence of the irritation of treatment 
with that of coitus will produce a more intense reaction by sum- 
mation of the irritation, and that an interval of at least forty- 
eight hours should elapse between local interference and coitus. 

It is evident that we must also consider the general nutri- 
tive condition, and that any disturbances, which not infre- 
quently react on the blenorrhcea, must be treated. The 
neurasthenic symptoms associated with chronic posterior 
urethritis, so long as they remain localized, recover not infre- 
quently as soon as the urethritis is cured. In other cases, es- 
pecially if they are more diffuse and spinal in character, they 
require special treatment after recovery of the urethritis. 



CHAPTEE IV. 

COMPLICATIONS OF BLENORRHCEA EST THE MALE. 

General Remarks. 

In a large number of cases gonorrhoea runs its course in 
the manner described above. In others, however, the process 
not alone has a tendency to spread along the surface of the 
mucous membrane, but also to extend to other tissues or 
organs. 

This extension occurs in two ways. Thus, the process may 
simply spread deeply, through the mucosa to the submucous 
tissue and other subjacent tissues, such as the corpus cav- 
ernosum. 

Or the process extends along the surface. This surface is 
not continuous, but is interrupted by a large number of excre- 
tory ducts of annexed glandular organs. Passing to these 
mucous membranes which are in direct continuity with the 
urethra, the inflammatory process extends to the glandular 
bodies themselves, in which it also sets up inflammation, such 
as folliculitis, cowperitis, prostatitis, vesiculitis, epididymitis. 

The bladder is also affected by direct spread of the disease, 
which may extend, in rare cases, through the ureters to the 
pelves of the kidneys and the kidneys. 

Finally, there is a third series of complications, which are 
common to both sexes, but in which the manner in which the 
morbid irritation is conveyed is unknown. These will be dis- 
cussed separately at the close. They include the more remote 
complications, such as rheumatism, iritis and endocarditis. 

The first two groups of complications, which are conveyed 
directly per continuitatem or per contiguitatem, usually ac- 
company acute inflammation. Some also complicate chronic 
blenorrhcea, viz., prostatis, vesiculitis, cystitis. 

Certain complications, cavernitis, cowperitis, occur in ante- 



Blenorrhcea of the Sexual Organs. 205 

rior urethritis; others, such as prostatitis, vesiculitis, epididy- 
mitis, cystitis, only follow posterior urethritis. 

We may therefore distinguish direct complications, result- 
ing from propagation of the process, and remote, metastatic 
complications. The former are subdivided into those which 
have developed per continuitatem and per contiguitatem. 

Finally, we must distinguish complications of acute and 
chronic urethritis, and those of anterior and posterior ure- 
thritis. 

The most important question concerns the mode of origin 
of these complicating inflammations : Are they also due to the 
gonococcus? 

This question has been recently answered in a manner which 
is diametrically opposed to our previous notions. 

Until recently there was no opposition to Bumm's opinion 
that the gonococcus only enters mucous membranes which pos- 
sess cylindrical epithelium, that it cannot vegetate upon and 
in pavement epithelium, and that it only produces superficial 
inflammations because it proliferates solely in the epithelium 
and the uppermost layers of the subepithelial connective tissue. 

Recent investigations have led to a decided change in these 
opinions. 

In the first place, Toulon (1889), Jadassohn (1890), Fabry 
(1891), and Pick (1891), have shown that gonococci may also 
grow upon the pavement epithelium of the para-urethral and 
preputial canals, which belong to the epidermal type. Fur- 
thermore, Wertheim (1892) proved that the gonococcus may 
also penetrate deep into the connective tissue, and produce in- 
flammation and suppuration. 

Investigations have shown, however, that the character of 
the epithelium plays a certain part in the immigration of the 
coccus. 

1. The epithelium of the para-urethral ducts, an epidermis- 
like pavement epithelium, appears to offer the greatest resist- 
ance to the gonococcus. Here it vegetates only upon the two 
or three upper layers of epithelium. 

2. The buccal mucous membrane, which has several layers 
of pavement epithelium, offers less resistance to the gonococ- 
cus. According to Rosinski's investigations on the gonorrhoeal 
aphthae of the new-born, it penetrates the epithelial cells, pushes 
along the interepithelial spaces, and is only prevented from en- 



206 Blenorrhcea of the Sexual Organs, 

tering the connective tissue by a firm tunica propria. In both 
these cases, however, the epithelium appears to prevent the en- 
trance of the coccus into the connective tissue. 

3. The conjunctiva and rectum, which possess several layers 
of cylindrical epithelium, appear to be penetrated rapidly by 
the gonococcus. According to Bumm's investigations, at all 
events, it rapidly passes in the conjunctiva to the upper layer 
of the subepithelial connective tissue. In the rectum, accord- 
ing to Frisch (1891), it passes through the subepithelial con- 
nective tissue to the muscular coat. 

4. Fallopian tube. This mucous membrane has a single 
layer of ciliated cylindrical epithelium. According to Wertheim 
(1892), its entire thickness ma}' be infiltrated with gonococci, 
as far as the outer peritoneal coat. 

5. Peritoneum. This is covered with a single layer of pave- 
ment epithelium. According to Wertheim's experiments on 
animals, the gonococci may penetrate freely into the connec- 
tive tissue at the end of twenty-four hours. 

The gonococcus may also proliferate freely in connective 
tissue and may excite intense inflammation. Thus Pellizzarri 
(1890) and Christiani (1891) have found the gonococcus in peri- 
urethral abscesses as the sole micro-organism. 

In two cases of inflammatory oedema of the prepuce, com- 
plicating a recent urethritis, Crippa (1893) found gonococci in 
the cedema fluid. Wertheim observed them as the causes of 
ovarian abscesses. 

At the present time, accordingly, it cannot be denied that 
all the complications of blenorrhcea, which develop per continu- 
itatem, in both sexes, may be due to the gonococcus alone. 

It would be a mistake, however, to attribute all these com- 
plications unreservedly to this micro-organism. Several pos- 
sibilities should be borne "in mind. 

In the first place, Lustgarten, Mannaberg, and Tommasoli 
have shown that the normal urethra and the prseputial sac 
contain pus cocci. Hence there is a possibility of mixed infec- 
tion, of the penetration of pus cocci into the mucous mem- 
brane which has been attacked by the gonococci. 

Furthermore, the staphylococcus pyogenes aureus has been 
found in g-onorrhceal pus and therefore upon the diseased mu- 
cous membrane. 

Finally, it should not be forgotten that the presence of pus 



Blenorrlioea of the Sexual Organs. 207 

cocci in certain complications of acute urethritis has been di- 
rectly demonstrated. Thus Bockhart found them in peri-ure- 
thral abscesses, and Bumm, Saenger, and Gersheim also found 
them, in addition to the gonococcus, in abscesses of Bartho- 
lin's giands. 

Wille found gonococci and streptococcus pyogenes aureus, 
in two cases, in the pus of pyosalpinx, while Bumm, Loven, 
Penrose, and Menge found only pus cocci in seven cases of pyo- 
salpinx which were undoubtedly due to gonorrhoea. 

Hence it cannot be denied that a complication of urethritis 
may also be produced by pus cocci. The mode of development 
of the complications is therefore threefold. 

(a) The complication is due solely to the gonococcus, is 
purely gonorrhceal in character. 

(b) The disease of the mucous membrane is merely the 
point of entrance for other pus cocci which produce the com- 
plication (mixed infection). 

(c) Or the gonococcus produces a complication, and pus 
cocci subsequently enter. These may co-exist for some time, 
then the gonococcus is destroyed and the pus coccus alone re- 
mains (secondary infection). 

Another series of complications, such as glandular disease, 
rheumatism, heart disease, cutaneous abscesses (Lang, 1893), 
develop metastatically. 

These complications may also develop in various wa3 T s. 

(a) The metastatic complication is due to the gonococcus, 
is purely gonorrhceal. The coccus may be transported through 
the lymph channels (lymphatic glands) or the blood-vessels 
(joints, heart, skin). Hamonic, Le Roy, Tedenat, and Jullien 
claim to have found the gonococcus in the blood, but this is de- 
nied by Trapesnikow. 

(6) The complication is due to mixed infection or secondary 
infection, and pus cocci are then found as the morbific agents. 

(c) The morbid foci contain neither gonococci nor pus cocci. 
The metastasis is then regarded as a ptomaine intoxication, 
whether correctly or not cannot be decided at the present time. 

I. BALANITIS. 

Etiology. 
Balanitis is a catarrhal inflammation of the surface of the 
glans and the inner layer of the prepuce. This is a complica- 



2o8 Blenorrhcea of the Sexual Organs. 

tion of blenorrhcea in a remote sense alone, inasmuch as it de- 
velops at the same time, but does not always depend genet- 
ically upon it. The development of balanitis is a double one 
in these cases. It not infrequently even precedes the urethritis. 
The superficial catarrhal inflammation is produced by local 
irritants of the most varied kinds — for example, by uncleanli- 
ness of all kinds, if deposited in the preputial sac and not 
removed early enough. Now, we notice that not infrequently 
balanitis develops soon after coitus, usually within twenty- 
four hours, while the clap does not begin until the fourth or 
fifth day. In such cases, as a matter of course, the balanitis is 
not caused by clap, but both have the same source, viz., impure 
coitus with a blenorrhagic female. But while the clap is due 
to the specific virus, simple balanitis is the result of the irri- 
tant action of the blenorrhagic or otherwise contaminated 
vaginal secretion. 

In other cases the balanitis develops during the course of 
gonorrhoea. The gonorrhceal pus itself then takes the part 
of irritant; it flows into the preputial sac, and if not removed 
w r ith sufficient frequency, gives rise to inflammation. But the 
role of the gonorrhceal secretion is then merely an irritating, 
non-specific one. Balanitis may result from various other 
causes, such as the irritation of glycosuric decomposing urine 
in diabetics. The secretion of balanitis contains the most 
varied forms of cocci and bacteria, also gonococci, if it has 
been mingled with gonorrhceal pus, but none of these micro- 
organisms occurs in such proportions that we may claim for 
it a part in the production of balanitis. 

Balanitis has also been looked upon as the consequence of 
an excessive amount of normal smegma, but this is erroneous. 
In hospital and dispensary practice we not infrequently see 
individuals who pay very little attention to the preputial sac, 
and in which the smegma collects for a long time in such 
quantities that it finally forms incrustations or preputial cal- 
culi. Nevertheless balanitis does not develop in such cases. 
On the other hand we find scrupulously clean individuals who 
can detect the beginning of balanitis if they omit cleaning the 
preputial sac for a single day. If we examine the smegma in 
such patients, it will be found to be a thin fluid, and it is this 
which proves especially irritating. Whether this condition of 
the smegma depends on morbid production or on decomposi- 



Blenorrhcea of the Sexual Organs. 209 

tion immediately after its formation, on account of local influ- 
ences, we must leave undecided. 

When the irritation of blenorrhagic secretion produces 
balanitis, a long- tight prepuce is a favoring- factor, because 
it interferes with the discharge of the gonorrheal pus exter- 
nally and retains it in the preputial sac. 

Symptomatology. 

The symptoms of balanitis are usually so simple and clear 
as to admit of no doubt. On examination of the penis exter- 
nally, we usually find no change, but sometimes the preputial 
sac appears distended, especially in the region of the corona 
glandis. In unclean patients we will be struck by the amount 
of pus which soils the clothes, an amount greater than that 
produced in acute bienorrhoea in some time. Crusts of dried 
pus are usually found at the edge of the prepuce. If the pre- 
puce is drawn back and the glans exposed, an abundance of 
thin, foul-smelling pus escapes, and, after its removal, the 
inner layer of the prepuce is found to be slightly swollen, 
reddened, and loosened. The surface of the inner layer is 
often velvety, even presents small, mulberry-like nodules, is 
destitute of epithelium, and bleeds easily on contact. These 
appearances increase from without inwards and are most in- 
tense in the coronary sulcus. They are less marked on the 
glans. In the severest cases the entire surface of the glans is 
reddened, eroded and secreting. In milder cases we find only 
superficial eroded patches, or the corona is the site of an ex- 
tensive erosion, which diminishes towards the glans, the latter 
presenting only one or a few small erosions. A somewhat an- 
noying itching and pricking in the coronary sulcus, associated 
at the most with slightly increased sexual excitability, are 
the sole symptoms of this condition. 

In other cases the inflammation is more severe, the entire 
prepuce is involved and appears slightly oedematous, thus in- 
terfering with its retraction. The secretion is more abundant. 
We then find upon the glans a series of sharply defined, red 
patches, deprived of epithelium, with jagged, map-like con- 
tours. They usually coalesce towards the corona glandis. 
Pain is generally present in these cases, especially on contact, 
and is annoying to the patient in walking or on friction of the 
14 



210 Blenorrhcea of the Sexual Organs. 

underclothing" against the penis. Erections are accompanied 
by violent pains, resulting- from the stretching- of the prepuce 
by the erect g-lans. 

If the inflammation is more severe, the lymphatics which 
originate in the coronary sulcus are involved. We then find 
doughy, very sensitive nodular infiltrations which start from 
the sulcus and are situated beneath its covering and the skin 
of the penis. On complete retraction of the prepuce they pro- 
ject like a hemisphere beneath its inner lamella. These infil- 
trations are either circumscribed or they are connected by 
narrow bands with the lymphatic plexus of the dorsum penis, 
which is then swollen and painful. 

If the inflammatory symptoms progress the oedema of the 
prepuce also increases. The entire penis then assumes the 
shape of a club, which is larger towards the gians. In these 
cases reposition of the prepuce is no longer possible (phimosis). 
If the inflammatory swelling and oedema increase still more, 
the mutual pressure of the glans and prepuce may give rise to 
circulatory disturbances, or even partial cessation of circula- 
tion, which then results in gangrene. As the gangrene is 
always moist, an ichorous, instead of a purulent, secretion 
takes place from the preputial sac. The prepuce then has a 
dark red, livid red or even blue color, and if it is incised, as is 
absolutely indicated in such cases, the inner layer of the pre- 
puce, more rarely a portion of the corona glandis, is found 
converted into a putrid, spongy, ichorous mass. If left to itself 
the gangrene of the inner layer usually penetrates, at some 
point, through the entire prepuce, especially on the dorsum. 
An opening is thus formed in the prepuce, through which the 
glans forces its way. This relieves the circulatory disturbance, 
the gangrenous portions are exfoliated, and recovery occurs 
by means of granulations and cicatrization. The rest of the 
prepuce shrivels, and hangs from the bare glans as an apron- 
like appendix. The general condition usually suffers, fever and 
even indications of stupor set in, but, on the other hand, there 
may be complete apyrexia without constitutional symptoms. 

In the milder cases — with moderate oedema and without 
gangrene — complete absorption usually follows. But in some 
the absorption is incomplete, and slight thickening of the in- 
tegument of the prepuce remains. If these attacks of balanitis 
with oedema recur, and the absorption remains incomplete, 



Blenorrhoea of the Sexual Organs. 2 1 1 

rigidity and thickening* of the prepuce finally result, and its 
reposition is interfered with or made impossible. Such a rig-id, 
elephantiatic prepuce is apt to be fissured during* coitus, es- 
pecially at the margin, and thus predisposes to infection. The 
fissures, which are easily inflamed, soiled by urine, and heal 
with difficult}^ give rise, if frequently repeated, to constantly 
increasing* sclerosis and narrowing* of the opening*. 

If erosions on the glans and inner layer of the prepuce are 
in apposition during a balanitis, and remain in contact for a long- 
time on account of phimosis, they may finally result in partial 
adhesions. Even complete adhesions may form over a larg*er or 
smaller surface, starting* from the coronary sulcus and ex- 
tending* over the corona to the middle of the gians, etc. The 
line at which the adhesion ceases, becoming* eroded by a fresh 
balanitis, gives rise to extension of the adhesion, which may 
advance finally to the orifice of the urethra. 

As a matter of course, balanitis cannot develop when the 
preputial sac is absent, as in circumcised individuals. But 
ritual circumcisions are often performed roughly with the aid 
of sharp finger nails, instead of the knife, and the glans is thus 
injured. The remains of the prepuce may then adhere to 
these injured spots, and span the coronary sulcus like a bridge. 
In the cavities which are formed in this way a catarrhal in- 
flammation, which is entirely analogous to balanitis, may de- 
velop, and if neglected, may give rise to swelling of the bridge- 
shaped remains of the prepuce, to pain and often to quite 
violent inflammatory symptoms. 

Mannino (1889) mentions several other complications of 
balanoposthitis. 1. Multiple indurated glandular swellings in 
lymphatic individuals. 2. Ulcers which resemble soft chancre. 
They are usually multiple and furnish typical pustules on in- 
oculation, but they differ from soft chancre only by their 
spontaneous development upon the basis of a balanitis. They 
furnish a pregnant illustration of my opinion that soft chancre 
is not a specific virulent affection, but is the product of the in- 
oculation of pus or the different pus producers. This is ex- 
plained by Tommasolr's finding of pus cocci (streptococcus and 
staphylococcus) in the normal preputial secretion and in that 
of balanitis. If an individual whose preputial secretion nor- 
mally contains pus cocci suffers from balanitis, the pus 
cocci which enter the erosions of balanitis will produce suppu- 



212 BlenorrJicea of the Sexual Organs. 

ration, i.e., soft chancre. 3. These " soft chancres/' especially 
when situated in the coronary sulcus, may have a firm base 
and simulate induration. My anatomical investigations have 
explained the development of this induration. Inoculation of 
these firm ulcers produces the characteristic inoculation pus- 
tule. 



Diagnosis and Differential Diagnosis. 

The diagnosis is evident from the above-mentioned symp- 
toms, and we might imagine that there can be no doubt in 
cases in which retraction of the prepuce is possible. Never- 
theless, mistakes are often made in such cases, and urethritis 
and balanitis are often confounded. In cases of abundant 
purulent secretion from the urethra, when the prepuce is long 
and narrow, the secretion will flow into the preputial sac. If 
the prepuce is now retracted and the glans laid bare, expos- 
ing at the same time the inner layer, both appear to be cov- 
ered with pus, which really comes from the urethra. This 
appearance leads careless observers to make the diagnosis of 
balanitis. In order to avoid mistakes it must be remembered 
that in balanitis the surface of the glans and inner layer of 
prepuce is not alone covered with pus, but also reddened, 
swollen and inflamed. If the pus is removed and the under- 
lying tissue found pale and normal, balanitis is excluded. 

But if these parts are found red and swollen it must also 
be remembered that an urethritis may also be present, in ad- 
dition to the balanitis. In order to convince ourselves the 
pus is wiped out of the preputial sac or washed away with 
the irrigator, after the patient has not urinated for several 
hours. Pressure is now made on the orifice of the urethra. 
If this forces pus from the urethra which contains gonococci 
under the microscope, the diagnosis is clear. If pus does not 
appear at the meatus, the patient is directed to urinate in two 
portions, and the cloudiness of one or both portions reveals 
the diagnosis and localization of the urethritis. 

If phimosis is present, the pus escapes from the orifice of 
the prepuce. There are then two possibilities. 1. Blenorrhoea 
may be combined with the phimosis, or, 2, the balanitis is the 
cause of the phimosis. We must then ascertain whether the 
suppuration comes from the preputial sac or from the urethra. 



Blenorrhoea of the Sexual Organs. 213 

In order to answer this question the patient is directed to hold 
his urine for several hours, and then the pus is washed out of 
the preputial sac by means of an irrigator and narrow drain- 
age tube, which is carried into the sac, or by a syringe with a 
long narrow tip, which may be inserted between the glans and 
prepuce. The patient then micturates. If the urine is clear, 
"the pus comes from the preputial sac, while a purulent cloudi- 
ness of the urine can only come from the urethra. 

But it must not be forgotten that when the suppuration is 
present in the preputial sac alone, i.e., when blenorrhoea is 
excluded, the balanitis may owe its origin to a soft chancre, 
to syphilis in all its stages, or to carcinoma. The pus of soft 
chancre is inoculable. It would, therefore, only be necessary 
to inoculate the patient by the aid of a lancet, with the pus 
obtained from the prepuce. But this procedure is usually 
superfluous, and is to be decidedly discountenanced in private 
practice. Nature often performs this inoculation for us. The 
pus flows upon the scrotum, thighs, margin of the prepuce, 
macerates these parts and produces eczema. These eroded 
and macerated places are infected by the pus, and we usually 
find, in such cases, soft chancres on the margin of the prepuce, 
scrotum and thighs. On the other hand, the phimosis offers 
favorable conditions for absorption of pus on account of its 
retention, and thus for the development of adenitides. Hence, 
soft chancres, which are complicated by phimosis, are usually 
followed by acute adenitis. 

If the phimosis results from a syphilitic sore, its rigidity is 
usually felt from the outside. An indolent, nodular lymphan- 
gioitis, multiple indolent glandular swellings, and recent sec- 
ondary symptoms, confirm the diagnosis. 

If the phimosis is the result of secondary papules — a rare 
event — the case is cleared up by other older symptoms of 
syphilis, papules on the buccal mucous membrane and around 
the anus, palmar and plantar psoriasis, pustules on the head, 
eruptions on the trunk. 

The diagnosis of phimosis due to gummata follows the 
demonstration of old syphilis, residua of the secondary period, 
old and recent tertiary symptoms. The diagnosis is further 
fortified by the long existence of a firm nodule, which is felt 
through the external coverings, by the absence of glandular 



214 Blenorrhoca of the Sexual Organs. 

enlargements and recent secondary symptoms, and finally by 
the results of treatment. 

When carcinoma is the cause of the phimosis we find con- 
siderable long-standing-, usually ichorous destruction of tissue ; 
absence of inflammatory symptoms; the characteristic, mul- 
tiple, metastatic glandular enlargements, as hard as bone, and 
a cachectic condition. 

Finally, acute development, slight increase in the size of 
the glans and absence of complications favor the diagnosis of 
balanitis alone as the cause of the phimosis. 

Treatment. 

In simple balanitis, uncomplicated with phimosis, whether 
with or without blenorrhcea, the treatment is quite simple. 
Cleansing and evacuation of the pus several times a day, dry- 
ing and isolation of the inflamed surfaces, are the indications. 
The patient bathes the penis, with the prepuce retracted, two 
or three times a day in not too cold water, to which carbolic 
acid or chloride of zinc (1 per cent.) has been added, then re- 
moves the pus with cotton and dries the parts. The glans is 
then covered with a thin layer of pure dry cotton, over which 
the prepuce is drawn. Or a bland powder, such as rice powder 
or talcum venetum, is strewn thickly on the glans and coron- 
ary sulcus, and the prepuce drawn over it. Erosions are cau- 
terized with solid nitrate of silver, or the entire preputial sac 
is brushed with a 50 per cent, solution. The patient m&y also 
use nitrate of silver (gr. vij. : 3 v.) for irrigation. Resorcin (5 to 
10 per cent, solution) as a bath, or brushed upon the preputial 
sac also gives good results. 

Chichester (1891) recommends brushing with 



^ Atropm. sulpb., 
Zinc, sulph., 
Acid, boric, 
Aq. destil., 



gr. f 
gr. iss. 
gr. iv. 
li. 



Tannin, used as a dusting powder, effects rapid recovery. 
This may also be applied for a long time to harden a delicate, 
tender glans and internal lamella, and thus prevent balanitis. 



Blenorrhcea of the Sexual Organs. 215 

If phimosis is present, the chief indication is the evacuation 
of the secretion. Recovery is usually effected rapidly by in- 
jections of a weak solution (gr. vij. : 3 v.) of nitrate of silver or 
resorcin (5 to 10 per cent.). Zeissl recommends rapid cauteri- 
zation by passing- the solid stick between the glans and inter- 
nal lamella. 

More violent inflammatory symptoms are combated by 
rest, elevation of the penis, moderate antiphlogosis ; oedema is 
relieved by scarifications. If the oedema is pronounced, and 
gangrene is threatening- or beginning-, we must avoid vigorous 
antiphlogosis, inasmuch as this favors the spread of the g-an- 
grene by interfering* still more with the circulation. 

If the phimosis cannot be relieved by antiphlogistics, and 
g-angrene is impending or has already developed, a dorsal in- 
cision must be made or circumcision performed. 

Balanitis in the bridged portions of the coronary sulcus 
heals on dividing the bridges with a bistoury or pair of scissors. 

When balanitis and phimosis are present, a coincident 
urethral gonorrhoea cannot be treated locally until the former 
have subsided. 

II. FOLLICULAR AND CAVERNOUS INFILTRATION AND 

ABSCESSES. 

Symptomatology. 

Although the blenorrhagic process is confined chiefly to 
the surface of the mucous membrane, there is hardly a case of 
acute urethritis in which at least some of the numerous folli- 
cles and glands in the mucous membrane are not implicated in 
the inflammatory process. We have already called attention 
to the fact that palpation of the pendulous portion during 
acute inflammation often reveals a series of larger or smaller 
nodules (sometimes as large as a hemp seed) which cannot be 
found in the normal urethra. These nodules — the larger ones 
are somewhat painful — are enlarged follicles. In many cases 
the inflammation is confined to the follicles, or spreads at most 
to the innermost layers of the peri-follicular connective tissue, 
and then constitutes a relatively slight affection. This can be 
followed most accurately at the orifice of the urethra. Both 
labia contain rather large follicles, which take part not infre- 
quently in the blenorrhagic process. We then notice some- 



216 Blenorrlioea of the Sexual Organs. 

what more marked swelling- and redness of the labia, and if 
the latter are separated, cleansed of pus and pressure exerted 
upon them, pus will escape on both sides from one or two nar- 
row openings. These openings, which admit fine probes, lead 
into canals -J to 1 ctr. long-. This affection is especially fre- 
quent in connection with slight hypospadias, when the glands 
and their openings are usually larger. 

The inflammation of the glands and follicles may become 
more intense and diffuse, the perifollicular tissue assuming a 
more prominent part. This is owing to the increased inflam- 
mation from occlusion of the excretory ducts, by inflammatory 
swelling or firmly adherent plugs of mucus and pus — a condi- 
tion that is apt to develop in view of the long, oblique course 
of the ducts through the mucous membrane. Or the inflam- 
mation may be intensified by external mechanical, traumatic 
and chemical irritants. 

At the frenulum the environs of these follicles are formed 
exclusively of connective tissue, which here occupies the entire 
breadth of the frenulum and fills up the space left by the cor- 
pus cavernosum glandis. At the frenulum, likewise, there are 
a large number of these follicles and glands, which empty into 
the fossa navicularis, and inflammation is frequent here. We 
then find on one or both sides of the frenulum, in the niche 
formed b}^ it with the coronary sulcus, a moderately firm, nod- 
ular swelling, covered by reddened skin, which is painful on 
pressure and may attain the size of a pea ; this soon softens, 
perforates and discharges a little pus. Examination with the 
probe shows a small cavity which does not usually communi- 
cate with the urethra. Rupture into the urethra is rare. If 
two symmetrical infiltrations form to the right and left of the 
frenulum at the same time, they often become confluent, push 
forward the frenulum, which presses upon the middle of the 
single nodule by a cicatrix and divides it into two halves. 
The suppuration in the nodule not infrequently coalesces before 
it ruptures externally, and, when this has happened, the probe 
discloses a cavity beneath the frenulum, opening on either 
side, and thus undermining the frenulum. CEdema of the 
glans and prepuce, pain on contact, erection and micturition, 
are the further symptoms of this still mild affection, which 
presents the disadvantage, however, of being apt to return on 
renewed infection. 



Blenorrhcea of the Sexual Organs. 217 

In all other parts, with the exception of the fossa navicu- 
laris, the giands and follicles are imbedded either in part or 
entirely in the cavernous tissue. If the inflammation extends 
beyond the boundaries of the follicular and perifollicular con- 
nective tissue, it must pass into the cavernous tissue. So-called 
cavernous infiltrations then develop from the perifollicular in- 
flammation. Starting- from a small, painless, follicular infiltra- 
tion there develops, usually rapidly and attended with quite 
violent pains, a nodule which may grow to the size of a pea or 
hazel nut. It is situated in the corpus cavernosum urethras, from 
which it projects like a nodule, and in the beginning- is covered 
by the movable integument of the penis. Violent pains, spon- 
taneous and on contact, exacerbation of the pains during- erec- 
tion, slight febrile movement, are the attendant symptoms. 
In some cases of marked swelling the stream of urine is ma- 
terially narrowed. Resolution may set in if the inflammation 
of the gland resulted from closure of the excretory duct and 
the plug becomes loosened. But the closure of the duct usually 
results from swelling of the mucous membrane over the 
nodule. Softening- of the nodule commonly occurs under such 
circumstances. The skin of the penis becomes reddened over 
the nodule and applied to it. In the meantime the internal 
wall, formed of the more delicate mucous membrane, may have 
yielded, the abscess discharges into the urethra, and a small 
flow of bloody pus escapes from the meatus. If urine enters 
the open abscess cavity at the next micturition, urinary infil- 
tration and extensive cavernitis may result. 

In other cases rupture occurs externally and internally at 
the same time. During micturition the urine passes through 
the internal opening into the abscess cavity and then out 
through the external opening. This diminishes the danger of 
urinary infiltration, but opens the way for a urinary fistula, 
inasmuch as the urine which escapes through the abscess cav- 
ity prevents complete healing. The most rare and favorable 
termination is that in which the abscess ruptures externally 
alone and then usually heals rapidly. 

These circumscribed infiltrations may develop in all parts 
of the pars cavernosa. The favorite site is the bulb, in the first 
place because this is very rich in glands and follicles, then be- 
cause stagnation of pus at the bulb and external injuries are 
apt to cause intensification of the inflammation. The swelling, 



2 1 8 Bleuorrhcea of the Sexual Organs. 

which is very painful and more extensive than in other parts, 
is not round but is sharply defined, round posteriorly, ter- 
minating in a point anteriorly; when very large, it always 
interferes with micturition, is accompanied by fever, and rap- 
idly softens. Rupture internally furnishes very favorable con- 
ditions for urinary infiltration, especially as the bulb is so well 
adapted for the stagnation of the urine left in the urethra. 

More extensive inflammations of the corpus cavernosum 
may also set in. These develop as the result of acute urethri- 
tis in various ways. They start from a folliculitis which has 
ruptured internally, from rupture of the urethral mucous 
membrane during vigorous erections, coitus, "breaking a 
chordee," or violent irritation affecting the inflamed mucous 
membrane. 

If the process was preceded by folliculitis with rupture in- 
ternally, the patient suffered first from the symptoms of the 
former affection, which rapidly improved after discharge of 
pus through the urethra attended by diminished size of the 
nodule. One or two days after the rupture, however, the 
former nodules increase rapidly in size and become very pain- 
ful, and the previously circumscribed swelling extends over a 
large part of or the entire corpus cavernosum penis. The in- 
tegument over the swelling is reddened, urination obstructed, 
the stream small and feeble, and micturition is attended 
with violent pain in the infiltration. The boundaries of the 
latter usually cannot be felt very distinctly. On account of 
this swelling the corpus cavernosum urethrse is fuller, as if 
semi-erect, so that the penis is curved, with the concavity 
towards the abdomen. If an erection occurs the corpus cav- 
ernosum urethras, whose meshes are swollen and its cavities 
narrowed on account of the inflammation, cannot accommo- 
date as much blood as the normal corpora cavernosa penis. 
It therefore becomes less erect and a curvature of the penis 
results, with the concavity dowmwards. This chordee is natu- 
rally attended with violent pain. If the cavernitis is due to 
urinary infiltration, purulent degeneration occurs with rupt- 
ure externally, unless a more grave sequel sets in, viz., ichor- 
ous, gangrenous destruction attended with severe febrile 
symptoms, which may prove fatal from pyaemia. If it is due 
simply to increase of the inflammatory phenomena, dependent 
on local irritation, the inflammation may terminate in resolu- 



BlenorrJicea of the Sexual Organs. 219 

tion. It may also end in induration, conversion into fibrous 
connective tissue, which then causes permanent disturbances 
of erection, chordee and impotentia coeundi from obliteration 
of a portion of the corpus cavernosum. In a case of this kind 
A. Guerin (1854) found, on autopsy, that the spongy tissue 
had disappeared completely, and that the bundles which form 
the alveoli were thickened and inelastic. Tarnowsky describes 
a case of extensive acute inflammation involving' all the erec- 
tile bodies. The patient had made an injection, by mistake, of 
a concentrated solution of nitrate of silver. Fifteen hours 
later Tarnowsky found him in bed, the penis completely erect, 
the skin reddened and hot, the slightest movement, even a 
current of air, produced the most violent pains. Bloody pus 
escaped from the urethra. Urination was impossible on ac- 
count of the agonizing- pains produced by the passage of urine 
through the canal. Even when at rest the pain was felt not 
alone in the entire penis, but also extended to the perineum, 
and was increased to the utmost by adduction of the thighs, 
so that the patient was forced to assume a semi-recumbent 
position with the thighs adducted and flexed at the knees. 
Leeches to the perineum, ice compresses, and inunctions of 
gray ointment resulted in resolution, but three months later 
an elongated induration, as large as a hazel nut, could still be 
felt at the middle of one of the lateral walls of the penis. 

Chronic gonorrhoea is followed by complications of this 
kind much more rarely than the acute form. As the result of 
exacerbations the process sometimes spreads to one or the 
other follicle or gland, but the course of this folliculitis is sub- 
acute, and usually terminates in induration. On palpating 
the urethra of a man suffering from chronic gonorrhoea we 
then find one or more painless, firm nodules, perhaps as large 
as a hemp seed, in the course of the corpus cavernosum 
urethral. 

Stricture is a not infrequent cause of peri-urethral cavern- 
ous infiltrations in old chronic urethritis. Ulceration with 
urinary infiltration is a not uncommon retro-strictural change, 
and may give rise to cavernous infiltration. Inasmuch as 
the bulb is the favorite site of stricture, these changes are 
usually located immediately behind it in the pars membran- 
acea, but may also appear in other places. 

Kreiner reports a remarkably severe case of this kind, in 



220 Blenorrhcea of the Sexual Organs. 

which there is doubt as to the origin from acute or chronic 
urethritis, because the patient did not come under observation 
until the changes were completed. In a waiter, set. twenty- 
one years, who had entirely neglected a urethritis for three 
years, the following condition was observed : the penis is of 
moderate size as if semi-erect, curved slightly to one side, the 
glans disproportionately thick, of a bluish livid color, with 
numerous openings resembling the prick of a needle. The 
posterior segment of the frenulum prasputii is very thick, and 
two rather large openings are found on either side. On pal- 
pation the urethra and its corpus cavernosum, from the mid- 
dle of the pendulous portion to the external orifice, is found to 
be very thick and hard, as if it contained an elastic catheter 
of large calibre. Here and there an induration as large as a 
pea. The glans penis feels like a large callosity, the meatus is 
retracted by cicatricial tissue and very narrow, so that only a 
fine bougie is introduced with difficulty ; it is almost entirely 
covered by proliferating granulations which start from its 
ulcerated border. If the urethra is squeezed moderately from 
behind forwards, creamy pus appears not alone at the meatus 
but also at the previously mentioned openings in the glans, as 
if from a sieve. The patient micturates with difficulty, using 
the abdominal muscles, and the stream is very small and 
spiral; the urine trickles from the openings in the glans and 
spirts in two very fine streams from the openings alongside 
the frenulum. This also occurs if fluid is injected into the 
urethra by means of Sigmund's syringe. 

Finally, we must mention another change, viz., chronic in- 
duration of the corpora cavernosa, which does not follow 
florid blenorrhoeas, whether acute or chronic, but develops in 
an insidious manner after such processes have run their 
course. This condition is mentioned by Tarnowsky, Van Buren 
and Keyes and Mauriac. 

This consists of a painless, chronic thickening of the cor- 
pora cavernosa. The patient first experiences some pain dur- 
ing erection, and on palpation finds a firm nodule in one of the 
corpora cavernosa. This can also be felt when the penis is 
flaccid. It slowly enlarges. When it becomes almost as wide 
as the corpus cavernosum it causes disturbance during erec- 
tion, but remains firm and painless. If the size increases still 
more, the penis becomes bent during erection. In some cases 



Blenorrkcea of the Sextial Organs. 221 

the induration has a flat shape, is firm and elastic but stretches 
very little, so that it hinders erection; it never extends through 
the entire thickness of the corpus cavernosum. Several 
nodules sometimes develop in one or both corpora cavernosa. 

The diagnosis of these forms is evident from the symptom- 
atology. Acute forms, without coincident blenorrhoea, are not 
observed unless there have been local injuries of a traumatic 
nature. The inflammatory symptoms, the infiltration felt on 
palpation, the demonstration of blenorrhoea, enable us to make 
the diagnosis without difficulty. In chronic induration syphi- 
lis must be taken into consideration. The previous history 
and the demonstration of luetic symptoms furnish the basis 
for treatment, which is also effective in the blenorrhagic affec- 
tion. 

The prognosis should never be made unqualifiedly favora- 
ble. Even the mildest forms of follicular abscesses may give 
rise to urinary infiltration. This condition always impairs the 
prognosis materially, on account of the danger to the potentia 
coeundi from extensive destruction of the corpus cavernosum, 
the possibility of a permanent urinary fistula, finally, of 
pyasmic symptoms. Chronic induration, which is with diffi- 
culty amenable to treatment, cannot endanger life, but 
threatens the potentia coeundi. 

Treatment. 

The first indication is complete rest, of the body as well as 
of the genitalia. If possible the patient should be kept in bed, 
sexual excitement combated in the well-known ways, the food 
should be bland, and easy evacuations should be secured. All 
local treatment of the gonorrhoea, whether external or inter- 
nal, should be discontinued at once. 

In recent infiltrations, which show no softening or fluctua- 
tion, vigorous antiphlogistic measures must be adopted at 
once. Cold compresses are first applied assiduously. When 
the pain has disappeared, absorption is aided by inunctions of 
gray ointment. If fluctuation or softening is noticed, immedi- 
ate incision will prevent rupture internally. If rupture inter- 
nally has occurred, communication is established by incision 
of the abscess externally, and the case treated according to 
surgical principles. Threatening urinary infiltration and fis- 



222 Blenorrhoea of tJie Sexual Organs. 

tula are avoided by the introduction of an elastic catheter a 
demeure. This should also be done, and an external incision 
made, even after urinary infiltration has occurred. 

If a fistula remains after recovery, it must be treated sur- 
gically. Indurations, whether chronic or the residua of acute 
inflammation, are treated with vapor compresses and applica- 
tion of iodine. Until the infiltrations have entirely disap- 
peared, erections and coitus must be prevented, because they 
may be followed by very serious consequences as the result of 
rupture and hemorrhage. 

Folliculitides of the urethral meatus are treated by the 
passage of a narrow stick of lunar caustic or hot needles into 
the gland. If hypospadias is also present, the excretory duct 
of the gland may be divided. 

In undermining of the frenulum by abscesses complete 
division of the remaining bridges is indicated. 



III. INFLAMMATION OF COWPER'S GLANDS. 

General Remarks. 

Although Cowper's glands had been described by Mery in 
1684, and Cowper described them anew in 1702, their pathology 
long remained obscure. Cowper attributed the discharge of 
vitreous, tough fluid at the end of an urethritis to disease of 
these glands, and also reported a case of ulceration of the 
excretory duct. Littre (1711) also brought chronic urethritides 
in connection with disease of Cowper's glands, and described a 
case of swelling of the gland with ulceration of the excretory 
duct. In an autopsy on a young man Morgagni found nar- 
rowing of the excretory duct as the result of a cicatrix. 
Hunter mentioned Cowperitis cursorily, and recommends vig- 
orous treatment with mercury. B. Bell regarded it as a dan- 
gerous complication of urethritis, which gives rise, in some 
cases, to an incurable urethral discharge. Swediaur men- 
tioned retention of urine from enlargement of the gland. 
Gubler (1849) was the first to give a detailed account of the 
diseases of Cowper's glands in a thesis prepared under 
Bicord's supervision. In 1849 Linhart presented to the Vienna 
Medical Society two preparations, one of suppuration of Cow- 
per's gland with gangrene of the mucous membrane of the 



Blenorrhcea of the Sexual Organs. 223 

urethra, the other of suppuration of the middle lobe of the 
gland. Other cases have been reported by Bartels, Mcolle, 
Ravogli and Rasori, and Bowie, but the affection is rare and 
relatively little studied. 



Symptomatology. 

Acute Cowperitis is almost always a complication of acute 
gonorrhoea. At the end of the second week after infection the 
inflammation reaches the bulb into which the excretory ducts 
of Cowper's glands empty, so that Cowperitis cannot develop 
before this period. Fournier states that the third and fourth 
weeks of acute urethritis are the favorite period for the occur- 
rence of this complication. 

In some cases the spread of the inflammation is provoked 
by injuries which increase the intensity of the blenorrhcea, 
such as traumata, excessive movement, riding, dancing, coitus, 
strong injections or introduction of bougies. In other cases 
no exciting causes are found, the inflammation appears to 
develop spontaneously. In Tarnowsky's case an acute Cow- 
peritis developed in a chronic urethritis of two years standing, 
as the result of prolonged riding. 

The symptoms and course of the disease are usually simple. 
At first the patient generally feels a sticking- pain in the 
perineum, which leads him to make an examination. On pal- 
pation, which is always accompanied by pain, a sharply defined 
nodule is felt a little behind the bulb, i.e., about half way 
between the posterior edge of the scrotum and the anus, and 
to the side of the median line. This is about as larg*e as a 
hazel nut at the beginning, grows more or less rapidly, is 
sharply defined and covered by movable integument. The 
blenorrhagic secretion from the urethra diminishes or ceases 
entirely. Micturition is undisturbed, defecation is attended 
with pain in the perineum. The clinical history is not infre- 
quently confined to these symptoms, which diminish, and the 
disease is then cured or the inflammatory symptoms disap- 
pear, while the nodule remains and becomes indurated. 

In other cases, however, the inflammation progresses, the 
nodule becomes as large as a nut or even larger, and the skin 
is pushed forward. It usually loses its sharp boundary and be- 
comes elongated, the anterior smaller extremity reaching to 



224 Ble?torrhcea of the Sexual Organs. 

the bulb, or it extends along- the corpus cavernosum while the 
posterior blunt extremity ends at the transverse perineal 
fascia. The inner border may reach the median line or even 
pass beyond it, but the tumor is always asymmetrical on 
account of its predominantly lateral development. The swell- 
ing then has a doughy feel and is covered by inflamed, red- 
dened skin. Compression of the urethra in these cases inter- 
feres with micturition, the stream is narrow, the symptoms 
like those of stricture. 

Fever, chills and throbbing pains in the tumor are signs of 
beginning suppuration, which usually perforates externally in 
a few days, and often discharges astonishing amounts of pus. 
The pain and disturbances of micturition then cease, and the 
urethral discharge, if it has been in abeyance, returns. The 
abscess cavity fills with granulations and usually heals rapidly. 
The retraction of the recently formed cicatricial tissues may 
cause compression and distortion of the urethra and thus nar- 
rowing of its lumen, as in Barters case. 

Perforation internal^ is more rare, and still rarer is per- 
foration in both directions at the same time. Much then 
depends upon the course followed by the urine. Even despite 
perforation internally the urine does not enter the abscess 
cavity in many cases, and recovery rapidly follows. In such 
cases the perforation may be situated in such a position that 
the stream of urine, which distends the urethra, closes the 
opening. The urine may also not escape when the perfo- 
ration has taken place internally and externally. In other 
cases the urine enters the abscess cavity and then passes 
through the perineum, if external rupture takes place. Uri- 
nary infiltration and fistula are the result. 

But Cowperitis does not always run such an acute course 
in all cases. Tuffier reports the case of a patient, set. sixty 
years, who died of emphysema. He had suffered from blenor- 
rhcea and dysuria, which were found, during life, to be due to 
stricture of the urethra. The autopsy showed that the strict- 
ure resulted from an abscess of Cowper's gland which pro- 
jected into the urethra. In Hamonic's case a man of twenty- 
two years, of a tuberculous family, who presented the symp- 
toms of bronchitis at the apex, acquired an urethritis. In the 
third week a painless tumor developed in the perineum. 
Five weeks after infection it was as large as a walnut, pain 



Blenorrhcea of the Sexual Organs. 225 

less, doughy, covered with pale skin, and fluctuating*. The 
tuber ischii was tender on pressure and appeared to be con- 
nected with the tumor by a band. Hamonic made a diagnosis 
of cold abscess from disease of the os ischii. An incision 
discharged pale yellow pus, but no rough bone could be felt. 
The abscess cavity was lined by a thick pyogenic membrane. 
Extirpation and anatomical examination showed inflammation 
of Cowper's g*land. Tuberculosis was excluded histologically 
and bacteriologically. 

Bilateral Cowperitis is rarer than the unilateral form. 
The symptoms are the same, but the swelling- is bilateral or 
symmetrical from confluence. The pressure on the urethra 
and the subjective symptoms are more marked. Perforation 
externally is usually later on one side than on the other, and 
this leads not infrequently to communication of both abscesses 
and thus to exposure of the posterior periphery of the bulb ; 
this may result in serious fibrous compression when the 
abscess heals. In these cases the infiltration in the perineum 
generally extends to the anal opening 1 and upward along* the 
latter, but is always separated from the prostate by a groove. 

According* to Ricordi and Jullien, chronic Cowperitis runs 
a different course, being- manifested only by a morbid secretion 
without subjective symptoms. In some cases this secretion is 
opaline and occasionally becomes purulent, and cannot be dis- 
tinguished from that of chronic urethritis. In other cases the 
discharge, which passes the meatus in the morning-, is a gelat- 
inous, stringy mass, which is found under the microscope to 
contain the epithelium of Cowper's glands. 

In the absence of post-mortem examinations and the strik- 
ing- similarity of the symptoms with those of chronic urethritis, 
the question of the existence of chronic Cowperitis must re- 
main an open one. I have never observed such cases. 

Diagnosis and Differential Diagnosis. 

This is evident from the symptoms, but it is especially the 
inflammation limited to the gland which cannot easily be mis- 
taken. In advanced cases the diagnosis becomes more diffi- 
cult. It is then possible to mistake it for simple cutaneous 
abscess of the perineum, cavernous infiltrations and abscesses 
of the bulb. The cutaneous abscesses, however larg-e they 
15 



226 Blenorrhoea of the Sexual Organs. 

may be, are not apt to cause compression of the bulb. Ab- 
scesses of the bulb are distinguished by their median, more 
anterior position, from the asymmetrical, more posterior 
Cowperitides. Urinary infiltrations resulting from stricture 
are recognized by the fact that they follow chronic urethritis, 
have long been preceded by symptoms of narrowing, and that 
the narrowing does not disappear after perforation or incision. 

Prognosis. 

This is favorable when the disease is confined to the gland, 
but a guarded prognosis should always be given when the 
inflammation extends to the peri-glandular tissue, inasmuch 
as urinary infiltration, fistula, and fibrous compression of the 
urethra may give rise to disagreeable or even dangerous- 
S3 7 mptoms. 

Treatment. 

This consists simply of the cessation of all local treatment 
of the urethritis, rest, and cold compresses and ice-bags to the 
perineum in the acute stage, if no fluctuation is felt. If fluct- 
uation is present it must be treated surgically by immediate 
incision. Induration of the gland or peri-glandular tissue dis- 
appears on inunction of gray ointment or application of vapor 
compresses. 

IV. INFLAMMATION OF THE PROSTATE. 

General Remarks. 

That the prostate may take an active part in the blenor- 
rhagic process is an old experience. Indeed the part played 
by this organ was often exaggerated in former times. Thus, 
Zeller, Littre and Warren regarded clap as an inflam- 
mation and suppuration of the prostate. This view was 
owing to the fact that an autopsy is rarely held on simple, 
uncomplicated gonorrhoea and only as the result of intercur- 
rent affections, while urethritis only terminates fatally when 
aggravated by severe complications, among the most promi- 
nent of which is prostatitis. 



Blenorrhoea of the Sexual Organs. 227 

The prostate also played a large part in the pathology of 
clap even after clearer views of the nature of the disease were 
entertained. Thus, Swediaur and Girtanner (1803) located 
chronic blenorrhcea in the prostate, claiming- that the latter 
was more or less affected in almost every case. The prostate 
sometimes remained swollen, large and hard, even after com- 
plete recovery from the clap. The hardness and enlargement 
increase until finally the prostate occludes the neck of the 
"bladder. Wendt (182T) thought that the prostate is more or 
less implicated in every violent gonorrhoea, and Vidal (1854) 
believed that clap plays its part in the etiology of prostatic 
hypertrophy of old age. 

Accurate investigations have shown that the prostate 
may be affected as the result of acute as well as of chronic 
gonorrhoea. We must therefore distinguish acute as well 
as chronic diseases of the prostate, which generally follow 
the corresponding forms of urethritis. The spread of the 
process is due to various causes, but they always consist of 
irritants which gives rise to exacerbations of the urethritis,. 
such as excesses in Baccho et Venere, immoderate exercise, 
local irritation (strong injections, catheterization, etc.). Cer- 
tain prostatitides develop spontaneously or at least without 
any ascertainable cause. The ready passage of the inflamma- 
tion from the mucous membrane to the prostate is explained 
by their intimate anatomical connection. 

Symptomatology. 

Acute Prostatitis. — Implication of the prostate in acute 
urethritis from direct continuation of the inflammation from 
the mucous membrane can only occur, as a matter of course, 
when the pars prostatica is the site of the blenorrhagic proc- 
ess. Hence posterior urethritis alone is followed by prosta- 
titis, and the latter will not appear until the third week after 
infection. An exception obtains in those cases in which pus 
is carried into the pars posterior at the beginning of an acute 
urethritis by instrumental examination. 

According as the extension of the blenorrhagic process to 
the pars posterior occurs acutely (on account of external in- 
juries) or spontaneously and slowly, it will be accompanied by 
the well-known symptoms or run a latent course. 



228 Blenorrhcea of the Sexual Organs. 

The development of prostatitis is therefore either preceded 
by the symptoms of acute posterior urethritis or the latter 
are absent. 

Or the extension of the process to the pars posterior may 
be almost or entirely coincident with the acute prostatitis, so 
that the symptoms of both will occur together. 

I cannot state in figures the frequency with which acute 
posterior urethritis is complicated by prostatitis, but it is un- 
doubtedly very frequent. Sigmund (1858) believed that every 
clap which had lasted several weeks was followed by swelling 
of the prostate, which is often very considerable, and which 
may not disappear even after recovery from the clap. Mon- 
tagnon and Eraud state that the prostate is attacked in 70 
per cent, of the cases of posterior urethritis. 

The prostate may take part in acute posterior urethritis 
in four different ways. 

Congestion of the Prostate. — This is the most frequent 
form. The posterior urethritis has begun either in the well- 
known way or has developed in an entirely latent manner, 
when the patient complains of a feeling of pressure and 
weight in the perineum and fullness in the rectum. Vesical 
tenesmus is somewhat increased, and defecation is apt to be 
painful, especially if the faecal masses are firm. On examina- 
tion per rectum the prostate is found enlarged, either uni- 
formly or irregularly, feels warmer, and is painful on pressure. 
The urethral secretion does not diminish, the test of the two 
beakers shows cloudiness of both. This condition lasts so long 
as the acute stage of the blenorrhoea continues and disap- 
pears spontaneously in a few days. External irritants at this 
time, particularly injections and coitus, may increase the con- 
gestion and give rise to inflammation. Frequent pollutions, 
resulting from the increased sexual excitability induced by 
disease of the pars prostatica, may have the same effect. But 
we must be on our guard against declaring every tenderness 
of the prostate on pressure through the rectum as congestion, 
because this may be simulated by the mere tenderness of the 
pars prostatica. 

Acute Folliculitis. — Usually during the stage of acute 
posterior urethritis, or when exacerbation of an inflammation 
of the pars posterior, which has run its course, results from 
external injuries (injections, coitus, onanism), the patient ex- 



Blenorrhoea of the Sexual Organs. 229 

periences an increasing- vesical tenesmus, generally within six 
to twenty-four hours after the action of the exciting cause. 
As a rule the tenesmus lasts only a few hours, at the most a 
day, and compels the patient to urinate every half hour or even 
more frequently. The increased secretion of pus, which would 
otherwise have followed the exciting cause, remains absent, 
but both portions of urine are cloudy. The cloudiness is 
mucus, and is deposited after a long time in the shape of 
small flakes. The addition of acetic acid sometimes causes 
partial clearing up, an evidence that phosphaturia is also pres- 
ent. The contraction of the neck of the bladder on the pas- 
sage of the last drops of urine, and the elevation of the peri- 
neum by its muscles, are attended by a burning- or shooting 
pain which the patient often locates accurately in the same 
point. Micturition is also attended with a burning pain in a 
fixed point of the deepest portion of the urethra. On rectal 
examination the prostate hardly appears to be enlarged, but 
one or two firm nodules as large as a pea, which are sharply 
defined from the remaining soft parenchyma, can be felt, 
usually only in one lobe. Pressure on these nodules causes 
shooting pains. If no further morbific influences are at work 
the subjective symptoms disappear rapidly, the nodules are 
absorbed, and the original condition returns or an exacerba- 
tion of the urethritis sets in. If these nodules suppurate, they 
perforate towards the urethra and recover, leaving small cica- 
trices. When the latter are situated in the neighborhood of the 
ejaculatory duct, the} T may occlude the duct, as I have found on 
autopsy. Oligospermia is produced in unilateral closure of 
the duct, aspermatism in bilateral closure. 

Parenchymatous Prostatitis. — This may develop directry 
or from either of the previously mentioned forms. It usually 
begins with increased tenesmus, a feeling of fullness in the 
rectum and pressure on the perineum. The secretion disap- 
pears, fever sets in and all the symptoms are aggravated. 
Micturition is obstructed by the swelling of the prostate, and 
a small stream is discharged, with violent contraction of the 
abdominal muscles. Defecation is very painful from pressure 
on the swollen gland. At the same time there are spontane- 
ous, violent, shooting or boring pains in the perineum, which 
radiate towards and along the urethra, and also towards the 
rectum, small of the back, and thighs. Some patients describe 
a sensation of a painful " nut " in the rectum. Rectal tenes- 



230 Blenorrhoea of the Sextial Organs. 

mils is also distressing-. Pressure on the perineum is painful, 
jljo that the patients are usually unable to sit, but assume a 
recumbent position with flexed thighs. Rectal examination in 
these cases often shows very considerable swelling- of the 
prostate, which is tender on pressure, warm to the feel and 
projects far into the rectum. The symptoms increase in 
severity for five to six days. The enlargement of the gland 
may cause complete retention of urine and faeces which, asso- 
ciated with the constant vesical and rectal tenesmus, entails 
the greatest distress. Towards the end of the first week the 
symptoms may rapidly subside and the enlargement of the 
gland disappear, or suppuration occurs, attended with in- 
creased pains, which assume a throbbing- character, and chills 
which occur on one or more evenings. The purulent degenera- 
tion then proceeds rapidly, and distinct fluctuation is felt per 
rectum in three to four days. If the process is left to itself 
perforation sets in, the capsule in which the pus is situated 
yielding- at some point. If this is towards the urethra the pus 
will empty into the latter. The patient then experiences an 
acute pain, usually during defecation or micturition, and a 
stream of bloody pus flows from the urethra. The rupture 
is followed by rapid remission of all the symptoms. 

Or the capsule ruptures at some other point and the pus 
passes into the loose cellular tissue and between the fasciae of 
the pelvis. It may make its way either toward the rectum, 
into which it perforates, or towards the perineum. Here a 
swelling- forms, above which the skin reddens and softens, and 
rupture takes place. Various remarkable paths may also be 
followed by the pus. Among 102 cases, collated by Segond 
(1880), the discharge occurred in 

64 cases into the urethra. 
« « rectum. 
" " perineum. 
" " ischio-rectal fossa. 
" " inguinal region, 
through the obturator foramen. 
"' " umbilicus. 

" " sciatic foramen, 

at the edge of the false ribs, 
into the abdominal cavity. 
" " cavity of Retzius. 



43 


a 


15 


a 


8 


a 


3 


a 


2 


a 


1 


case 


1 


a 


1 


a 


1 


a 


1 


a 



Blenorrhcea of the Sexual Organs. 231 

In simple cases the formation of granulation now begins 
in the abscess cavity, and rapid recovery follows. 

But the proximity of the urethra, bladder, and rectum 
furnish so many dangers for inoculation, which may also occur 
from the outside. And so the entrance of urine or faeces, and 
therefore urinary infiltration, septic infection, gangrene and 
pyaemia, are not uncommon terminations. 

Coincident perforation into the urethra and the rectum or 
perineum may form an unnatural passage for the urine, which 
may lead to infiltration or the development of annoying 
fistulae. 

Parenchymatous prostatitis is, therefore, a very serious 
affection. Among Segond's 114 cases recovery occurred in 
70 cases; death occurred in 34 cases; urinary fistulae occurred 
in 10 cases. 

In addition to the termination in complete resolution and 
in suppuration there is a third and rarer termination, viz., 
induration. The acute symptoms and subjective phenomena 
disappear, but rectal examination shows that the prostate is 
distinctly enlarged and firm. This enlargement may diminish 
gradually, or it is followed by hypertrophy of the prostate. 

Unlike the acute forms just described some cases run an 
insidious, torpid course. Some external injury is followed by 
slight vesical tenesmus, which is not very annoying- to the 
patient. Local remedies are discontinued, but the secretion 
remains profuse. Five or six days later, during which time 
the patient attends to business, and can ride, walk and sit 
without difficulty, chill and fever set in, with some pain in 
urination and defecation. On examination per rectum we are 
greatly astonished to find a large, already fluctuating enlarge- 
ment of the prostate. Pitman describes a case of this kind 
and I have observed several, so that I lay it down as a rule 
that the prostate should be examined at once whenever fever 
occurs during the course of gonorrhoea. 

Periprostatic Phlegmons. — Paupert, Parmentier and Du- 
breuil call attention to the fact that inflammation of the peri- 
prostatic tissue results not so very rarely from the same 
causes as parenchymatous prostatitis. The prostate is sur- 
rounded by firm cellular tissue, especially behind and below. 
Collections of pus form here, and first extend upward between 
the prostate and rectum, and may even detach the perito- 



232 Blenorrhcea of the Sexual Organs. 

neum. The pus then usually seeks the perineum and may 
perforate here or even into the bulb of the urethra. It forms 
more rarely between the prostate and the urethra. The 
symptoms are very like those of acute prostatitis; the diag- 
nosis is based on examination per rectum which shows that 
the prostate is intact. As rupture occurs usually into the 
perineum, more rarely into the rectum, the course is generally 
favorable, and urinary infiltration and gangrene are not so 
much to be feared. 

Chronic Prostatitis. 

This may develop as the residuum of acute, especially fol- 
licular, prostatitis, or may begin as a chronic affection as a 
complication of chronic urethritis. It is so closely connected 
with the symptomatology of one of the forms of chronic pos- 
terior urethritis that we have already described it. I will here 
content myself with recalling attention to the cardinal symp- 
toms, prostatorrhoea and sexual neurasthenia, without enter- 
ing again into a detailed description. 

Pathological Anatomy 

Apart from the older autopsies, which refer chiefly to sup- 
purating prostatitis, we owe our knowledge of the pathological 
anatomy to Home, Hamilton and Thompson, though it is still 
defective on account of the lack of sufficient material. Thomp- 
son describes the changes in acute prostatitis as follows : The 
prostate is swollen to three or four times the normal, and feels 
firm and tough. The arteries are filled with dark blood, and 
the mucous membrane of the pars prostatica is dark red. On 
section the tissues appear redder than normal. Pressure ex- 
presses a large amount of reddish fluid, which is found, under 
the microscope, to consist of lymph, blood, prostatic fluid, and a 
small amount of pus. As the inflammation progresses the 
amount of pus increases, and on section through the lobes of 
the prostate, small drops of pus emerge from the glands. In 
advanced stages we find more or less numerous foci of pus, 
from the size of a hemp-seed to that of a pea, scattered through 
the substance of the prostate. This pus has one peculiarity, 
viz., that it is mucous, sticky, and mixed with blood. The 



Blenorrhoea of the Sexual Organs. 233 

prostate may be softened and gangrenous in small spots, the 
mucous membrane of the urethra is reddened and thickened, 
perhaps covered by false membranes, or it is partly destroj'ed 
by ulceration or gangrene. One or more of the purulent foci 
in the prostate empty directly upon the mucous membrane. 

In chronic prostatitis Thompson found the prostate some- 
times enlarged, sometimes very small, its consistence softened, 
even spongy. A section has a dark red to violet color, press- 
ure discharges abundant dark fluid. In advanced cases cir- 
cumscribed deposits of pus are found, perhaps as large as a 
hemp-seed. The mucous membrane of the pars prostatica is 
thinned and very vascular, the openings of the prostatic glands 
are extremely large ; more rarely the mucous membrane is 
thickened and has a livid red color. Pus is found not infre- 
quently in the sinus pocularis, the excretory ducts of the glands, 
and in small cavities which communicate with the urethra, and 
also in cavities within the periprostatic cellular tissue. In 
Fuerbringer's (1884) case, the gland was enlarged and infil- 
trated with broad, firm, ivory-white bands of cicatricial con- 
nective tissue. The walls of the excretory ducts were hyper- 
plastic and infiltrated with small cells; the ducts were dis- 
tended with an opaque mucous fluid like that described in the 
symptomatology of prostatorrhcea. The glandular tissue 
proper presented, in places, marked swelling and cloudiness 
of the epithelium with pronounced interstitial inflammation; 
no abscesses. 

Diagnosis and Prognosis. 

Acute prostatitis presents such typical symptoms that its 
diagnosis is unattended with difficulty. The only disease 
which may present analogous symptoms at the start is acute 
posterior urethritis, and this indeed takes part in the sympto- 
matology of prostatitis. The differential diagnosis is made by 
examination per rectum, which should, therefore, not be neg- 
lected in any case of acute urethritis posterior. It is in this 
way alone that we can detect recent congestions and follicular 
inflammations, and thus prevent more serious parenchymatous 
inflammations. 

The diagnosis of chronic prostatitis can be made at once 
by examination of the prostatorrhceic secretion, examination 
with the endoscope and sound, testing the urine, and by the 
recognition of sexual neurasthenia. 



234 Blenorrhcea of the Sexual Organs. 

The prognosis of acute prostatitis should be guarded. The 
congestion and follicular inflammation and many parenchy- 
matous inflammations terminate in resolution, hut the effects 
of the latter form, which are not always under our control, 
are so serious that caution is advisable, even if the process is 
running a favorable course. 

This is also true of chronic prostatitis, especially in view of 
the fact that the neurasthenia, which so frequently accom- 
panies it, may persist after recovery of the local symptoms. 

Treatment. 

Acute Prostatitis. — The chief point in every inflammation 
is rest. And so in acute prostatitis we must secure rest in bed, 
and also rest for the organ, i.e., avoid injections, give the well- 
known antaphrodisiacs {vide Treatment of Gonorrhoea) and se- 
cure easy and regular evacuations from the bowels. Strict anti- 
phlogosis is indicated so long as suppuration cannot be found. 
All former measures have become superfluous since I devised 
an apparatus which permits the local application of cold. This 
(Fig. 33) is analogous to Arzberger's hemorrhoidal apparatus. 
It consists of a narrow metallic tip, 16 cm. long, whose cavity 
is divided into two parts by a septum extending almost to the 
end, and is connected with two tubes. The well-oiled tip is 
inserted into the rectum, the widest portion resting directly 
on the prostate. Cold, or even ice-cold, water is now allowed 
to flow through by syphon action, and this cold is conveyed to 
the prostate. This apparatus, applied for an hour two or three 
times daily, has done excellent service so long as suppuration 
was not noticeable. Two days' use suffices to dispel the in- 
flammation, even in acute and considerable swellings. At 
the same time the instrument is easily inserted by the pa- 
tient himself. In addition, further antiphlogistic and sympto- 
matic treatment may be carried out. For example, inunc- 
tions of gray ointment to the perineum; if the pains and 
tenesmus are violent morphine internally, subcutaneously and 
as suppository. Narcotics are given to relieve the retention 
of urine, which, like the swelling, depends in great part on 
the spasm of the sphincters. It is only in case of urgent ne- 
cessity that an elastic, narrow catheter is carefully passed 
into the bladder, but is then allowed to remain. If suppura- 
tion sets in, the case must be treated according to surgical 



Blcnorrhcea of the Sexual Organs. 



235 



principles. An opening- should be made, if possible from the 
perineum. At all events this is to be preferred to opening* the 
abscess with the catheter from the urethra. If possible, i.e., 
if the catheter in such a case does not catch in the opened ab- 
scess cavity, a catheter a demeure is inserted after the rupt- 
ure into the urethra has taken place. 




Fig. 33. 



Chronic Prostatitis. — In this form the treatment of the 
prostatorrhoea and chronic urethritis is the most important. 

The prostatorrhoea may be treated by the use of Winter- 
nitz's psychrophore, which I have previously described. In 
many cases the apparatus shown in Fig. 33 has been very use- 



236 Blenorrhoea of the Sexual Organs. 

ful, but instead of cold water I apply warm water (37 to 42° 
C.) for an hour every day. Good results are also obtained 
from the subsequent application of the following" suppositories : 

^ Potass, iodid., gr. vij 

Iodin. p., gr. f 

Extr. belladon., gr. j 

Butyr. cacao q. s. f. suppositor. No. V. 
Koebner (1889) recommends enemata of the following- 
solution: 



^ Potass, iodid., 
Potass, bromid, 
Extract, belladon., 
Aq. destil., 



3iij. 
3 ij.-iij. 
gr. iiss. 

3X. 



This amount suffices for twenty enemata, two of which are 
given daily. Tincture of iodine, beginning with 3 drops and 
gradually increasing to 10 drops, may be added to each 
enema. Scharff (1892) recommends daily enemas of 10 to 50 
per cent, solutions of ammonium sulfo-ichtlryolicum. 

The urethral treatment consists of the application of solu- 
tions of nitrate of silver (1 to 5 per cent.) or potassium-iodide 
iodine-lanolin ointments, particularly the latter. Good results 
often follow the introduction of sounds of large calibre. 

The neurasthenia is often cured by the local treatment of 
the prostatitis. If neurasthenic symptoms remain after re- 
covery from the prostatitis and chronic urethritis, they are to 
be treated by the cold-water cure, iron and arsenic, sea bath- 
ing, Play fair's cure, according to the severity of the process. 

V. INFLAMMATION OF THE EPIDIDYMIS. 
General Kemarks. 

The knowledge of this, the most frequent complication of 
the blenorrhagic process, is almost as ancient as that of gon- 
orrhoea itself. But we possess no accurate data concerning- 
the frequency of its occurrence. 

Rollet observed 678 cases of epididymitis (27.9 per cent.) 
among 2425 cases of clap; Jullien 381 (15.2 per cent.) among- 
2500 cases; Tarnowsky 673 (12.2 per cent.) among- 5203 cases, 
and I observed during a five years' hospital service, 548 (29.9 per 
cent.) epididymitides among 1844 cases of urethritis. But all 



Blenorrhoea of the Sexual Organs. 237 

these figures are derived from hospital material, and hence are 
certainly too high, because it seems evident a priori that pa- 
tients suffering* from epididymitis, being unable to work, will 
then enter the hospital in larger numbers than those suffering 
from simple urethritis. In fact, Berg, taking- his statistics 
from private practice, states that he has seen epididymitis in 
7.5 per cent, of all urethritides. 

In the large majority of cases epididymitis is unilateral. 
It was maintained formerly that there is a great predominance 
on the left side, and various explanations were offered, for ex- 
ample, that the majority of men " dress " on the left side, so 
that the left testicle is exposed more readily to pressure and 
contusions. The predominance of left varicocele, the pressure 
exerted by the sigmoid flexure on the left vas deferens, were 
also mentioned as factors. But examination of a large statis- 
tical material shows that the difference between both sides is 
very small and requires no explanation. 

The situation of the epididymitis is given as follows : 





Right side. 


Left side. 


Both sides. 


Total, 


Gaussaille, 


45 


24 


4 


73 


D'Espine, 


12 


11 


6 


29 


Aubry, 


40 


52 


7 


99 


Castelnau, 


125 


133 


i 


265 


Curling, 


21 


14 


1 


36 


Sigmund, 


60 


48 


6 


114 


Fournier, 


102 


126 


35 


263 


Turati, 


191 


192 


25 


408 


Le Fort, 


249 


200 


41 


490 


Ramorino, 


29 


37 


— 


66 


Gamberini, 


15 


10 


3 


28 


Breda, 


64 


53 


4 


121 


Jullien, 


167 


182 


33 


382 


Kuehn, 


70 


67 


12 


149 


Unterberger, 


35 


25 


5 


65 


Author, 


275 


251 


22 


548 



1500 1425 211 3136 

From these tables _it appears that the difference between 
the two sides is extremely small, and that bilateral epididymi- 
tis is rare. 



2 3 8 



BlenorrJicea of the Sexual Organs. 



This complication results from the direct continuation of 
the blenorrhagic process, and will only develop after the proc- 
ess has reached the pars posterior. Hence the earliest period, 
as a rule, is the end of the second or beginning of the third 
week. Exceptions may arise if the gonorrhceal pus is carried 
mechanically, at an earlier period, into the pars posterior, 
here produces inflammation and propagation to the epididy- 
mis. The statistics of Fournier, Le Fort, Gaussaille, D'Espine, 
Aubry, Castelnau and Unterberger give the following results 
with regard to the onset of epididymis : 



1 week after infection in 


2 weeks 


3 


tt a a 


4 


(i a a 


5 


a a tt 


6 


it it tt 


7 


a a a 


8 


tt a tt 


3 months " 


4 


a a a 


5 


a a a 


6 


a a a 


7 


a ti it 


8 


u a tt 


9 


a a a 


to 12 


a a a 


2 


years " " 


3 


a a it 


4 


a a a 


7 


tt a a 



46 


cases. 


157 


a 


132 


a 


191 


a 


132 


tt 


64 


ft 


44 


tt 


61 


tt 


66 


tt 


33 


tt 


18 


tt 


22 


ft 


9 


'■t 


8 


tt 


5 


tt 


8 


tt 


9 


ft 


7 


tt 


2 


tt 


1 


case. 


1015 


cases 



Hence more than half of the cases (612 out of 1015) began 
two to five weeks after infection, and absolutely the larg-est 
number (191 cases) in the fourth week. Vidal and Sturgis also 
report the earlier occurrence of epididymitis, and even so criti- 
cal and experienced an observer as Bergh states that in two 
of his cases the epididymitis developed soon after exhaust- 
ing coitus, a few days before the discharge began, and in two 
others began with the discharge during the first week. 





264 


cases 




73 


u 




82 


a 




60 


it 




97 


a 



Blenorrhoea of the Sexual Organs. 239 

Nevertheless I am extremely skeptical concerning- such state- 
ments, not that the patient always intends to deceive us, but 
how many individuals suffer from chronic posterior urethritis 
without knowing" it, and cannot this produce epididymitis 
when an exacerbation results from pronounced morbific 
influences ? 

All those causes which give rise to exacerbations of urethri- 
tis, and which we have frequently referred to, also give rise to 
the development of epididymitis. Le Fort's statistics are 
interesting with regard to the statement so frequently made 
that the treatment of gonorrhoea is the chief cause of the de- 
velopment of epididymitis. 576 cases were classified as follows 
according to the previous treatment 

No treatment, 
Balsams alone, . 
Injections alone, 
Balsams and injections, . 
Treatment unknown. 

The untreated cases, accordingly, are those in which epi- 
didymitis is most frequent. This is probably not due exclu- 
sively to the absence of treatment, but it is to be assumed 
that careless patients will add positive injurious influences to 
the negative one of absence of treatment. These include ex- 
cesses in Baccho et venere, bodily strain, improper treatment. 

Despres (1878) attributes epididymitis to the retention of 
semen resulting from the continence rendered necessary by 
the blenorrhoea. It is true that individuals who remain con- 
tinent during a long-continued blenorrhoea, suffer from pain 
along the vas deferens, dragging- and heaviness in the testicles 
(seminal colic), but these are not apt to be mistaken for epi- 
didymitis, and we therefore adhere to the old view that this 
complication results much more often from losses than from 
retention of semen. 

The pathogen} 7 of epididymitis is not yet clear, but we will 
hardly go astray in regarding it as true blenorrhagic disease. 
Gonococci which have reached the pars posterior enter the 
ejaculatory duct and vas deferens, proliferate upon the sur- 
face of the epithelium, and finally reach the epididymis, where 
they produce inflammation. This inflammation, like all others 
which are due to gonococci, has less tendency to suppuration, 



240 Blenorrhcea of the Sexual Organs. 

but exhibits a decided tendency to pass into a chronic stage, 
which is characterized by the production of abundant cirrhotic 
connective tissue. 

According* to this view ever} T epididymitis would begin 
with a deferentitis. This is apparently contradicted by clini- 
cal observation, which shows that the disease begins in many 
cases in the epididymis, and the seminal duct is only affected 
later. 

This contradiction is only apparent. In the first place, 
epididymitis does begin with pain and tenderness along the 
seminal duct. Furthermore, the later affection of the duct 
is only apparent. 

So long as the gonococci multiply upon the epithelium 
of the vas deferens and reach the epididymis in this way, 
the clinically demonstrable implication of the former is slight. 
Those gonococci which remain in the vas deferens will pass 
through the epithelium into the connective tissue and sub- 
stance of the canal. This penetration into the tissues pro- 
duces the considerable thickening of the vas deferens which 
thus appears to follow the epididymitis. If the gonococci in 
the vas deferens or epididymis pass through these organs to 
the outer surface, they reach the serous cavity which sur- 
rounds a part of the vas deferens and the lateral borders of 
the epididymis. Here they produce acute inflammation with 
exudation, hydrocele testis et tunicge vaginalis. 

The frequency with which the vas deferens is affected is 
shown by Sigmund's statistics of 1,342 cases: 



Epididymitis with 


vaginalitis, 


. 


856- 


cases, 


<( 


a 


funiculitis, 


. 


108 


(t 


a 


it 


funiculitis and 


vaginalitis, 


317 


<t 


a 


alone, 


. 


61 


<( 



1,342 



Symptomatology. 



Acute epididymitis usually begins brusquely. A violent 
pain in the testicle is suddenly felt, " as if molten lead had 
dropped into the testicle," fever and malaise set in, and the 
disease is fully developed at the end of a few hours. 

In rarer cases prodromal symptoms are observed. The 



Blenorrhcea of the Sexual Organs. 241 

patients complain of general malaise, slight chilliness, and 
anorexia; then vesical tenesmus appears, with pain in the 
inguinal region, near the external ring, radiating towards the 
testicle and kidney, and finally persisting in the testicle. The 
secretion, which had been abundant hitherto, usually ceases. 
Among 141 cases examined by Aubry, the urethral secretion 
disappeared in 81, was materially diminished in 58 cases, and 
in only 2 cases did it increase with the onset of the epididymi- 
tis. 

The most constant, often the sole symptom, is a suddenly 
occurring, fixed pain in one testicle. On palpation the patient 
usually feels a swelling as large as a hazel nut or walnut. 
This swelling is confined at first to the head, more rarely to 
the tail of the epididymis, is sharply defined, and is extremely 
painful on palpation. 

The swelling extends very rapidly to the entire epididymis, 
and within twenty -four hours from the beginning of the affec- 
tion the enlargement is visible to the e3'e, the integument of 
the affected side of the scrotum is red, warm and tense. On 
examination the normal testicle is found surrounded above, 
behind, and below by a semilunar, moderately firm and ex- 
tremely painful swelling, the inflamed epididymis. 

In many cases the process remains at this stage. The en- 
largement and tenderness of the epididymis and the violent 
spontaneous pains increase for a few days. The patient, un- 
able to move on account of the threatened exacerbation of 
the pains, assumes the dorsal position in bed, and supports 
the affected side by drawing upon it and by partial flexion of 
the corresponding lower limb. In a few daj^s the pains dis- 
appear spontaneously, the inflammatory stage is over. 

In other cases the inflammation and swelling are not con- 
fined to the epididymis. It extends per continuitatem to the 
spermatic cord, attacking particularly the vas deferens. The 
latter appears firmer than normal, is tender on pressure, and 
can be traced into the external inguinal ring as a round cord 
as thick as a raven's quill. In some cases it can also be fol- 
lowed, per rectum, to the prostate as a firm, tender cord, and 
even the corresponding half of the prostate appears enlarged, 
firm and tender. 

The entire spermatic cord may also take part in the in- 
flammation. It is then swollen and shortened, so that the 
16 



242 BlenorrJioea of the Sexual Organs. 

affected testicle is drawn against the inguinal ring-, and is the 
site of violent pains. 

The inflammation may also extend to the tunica vaginalis, 
where it gives rise to increased effusion of fluid. At first the 
tunica vaginalis testis alone is attacked. Fluid escapes be- 
tween the two layers, an acute hydrocele testis develops. The 
size of the affected half of the scrotum is materially enlarged 
by this very considerable and rapidly increasing swelling. 
The testicle itself can no longer be felt. It is enclosed in front 
and on the sides by a tense fluctuating tumor, behind which 
is the firm enlargement of the epididymis. 

If, as a developmental anomaly, the two layers of the tunica 
vaginalis of the spermatic cord are not firmly adherent, an 
acute exudation may form between them, hydrocele acuta 
funiculi spermatid. We then find a fluctuating, tense, sausage- 
shaped tumor, which ends at the external inguinal ring. 

When the swelling has thus attained considerable dimen- 
sions, the integument of the corresponding half of the scro- 
tum does not remain entirely intact. It is stretched tightly 
over the tumor, and is also reddened, swollen, and adherent 
to the subcutaneous tissues (eczema glabrum). 

In such a case all the tissues of the affected half of the 
scrotum participate in the inflammation. Concerning the 
condition of the testicle, which is concealed on all sides, we 
can obtain no information, but it appears to be the least af- 
fected of all. 

All these changes may develop rapidly. The disease reaches 
its acme in four to five days, remains in statu quo for a few 
days, and then subsides, the inflammatory symptoms disap- 
pearing rapidly, while the swelling is absorbed very slowly. 

The course just described presents numerous variations. 

In the first place the onset of epididymitis may be very 
violent. 

The patient, who is suffering from acute urethritis, exposes 
Iiimself to some injury, and at the end of twelve to twenty- 
four hours is attacked, towards evening, by violent pains which 
cannot be localized accurately and involve the entire abdomen. 
The lower part of the abdomen is tympanitic, tense, and ex- 
tremely sensitive to touch, even to the pressure of the bed- 
clothes. There is high fever, reaching to 39.5° C or even 40° C. 
The pains increase from hour to hour, radiate into the sacral 



BlenorrJicea of the Sexual Organs. 243 

region and thighs ; eructations, singultus, nausea set in, finally 
vomiting of greenish bile-stained mucus, and collapse. The 
symptoms create the impression of foudroyant peritonitis, and 
internal incarceration is suspected. Acute delirium tremens 
may occur in drinkers. On the following morning, when the 
symptoms have subsided, the swelling of the epididymis is 
apparent. Unlike these acute prodromal symptoms, the epi- 
didymitis which supervenes is not always very acute, but may 
be confined to the epididymis or a portion of it. In these cases 
we evidently have to deal with symptoms of violent peritoneal 
irritation. Hunter was the first to direct attention to them. 

We have stated that the disease begins in the epididymis, 
whence it extends upwards to the vas deferens and prostate. 
In rare cases the process is reversed, the disease pursues a de- 
scending course. After vesical tenesmus and cessation of thfe 
secretion a partial swelling of the prostate occurs, confined to 
one lobe. The vas deferens, swollen to the size of a raven's 
quill, can soon be felt to one side, and it is not until three or 
four days later that a circumscribed and moderately painful 
swelling of the epididymis develops. This may increase to 
an acute extensive epididymitis as the result of external 
causes. In a few cases I have been able to confirm Bergh's 
observations on this point. 

The blenorrhagic inflammation may even be confined to 
the vas deferens, constituting pure chordonitis blenorrhagica. 
J. Bell (1794) was the first who observed a few cases of this 
kind. In one of these, which was carefully described, the 
patient, whose gonorrhoea! secretion suddenly ceased, began 
to complain of violent pain at the neck of the bladder, extend- 
ing towards the inguinal region and the testicle. A tumor 
suddenly developed below the inguinal ring, at first as thick 
as a raven's quill, and could be traced as far as the epididymis. 
The latter as well as the testicle was unaffected. The tumor 
rapidly increased in thickness until it was an inch in diameter, 
had an elongated, round, almost spindle shape, and extended 
to the upper part of the testicle. Gosselin reports another 
case. In a man of twenty-five years, who had suffered from 
blenorrhcea for five months, a swelling formed in the scrotum 
at the level of the head of the epididymis. It formed a nodule 
as large as a hazel nut, terminating above in a cord as thick 
as a raven's quill, and could be separated from the epididymis. 



244 Blenorrhoea of the Sexual Organs. 

Rectal examination showed nothing* abnormal. Bergh de- 
scribes a similar case. Kohn's patient, a servant suffering 
from urethritis, suddenly experienced pain in the right side of 
the scrotum after a paroxysm of coughing'. This increased, 
and fever, constipation and vomiting were superadded. A cylin- 
drical tumor developed in the right inguinal region, beginning 
at the external inguinal ring, passing into the right half of the 
scrotum without sharply defined boundary, and corresponding 
to the course of the right spermatic cord. The right testis 
and epididymis appeared intact. The vas deferens, normal 
below, passes into the tumor, the skin over it is tightly 
stretched, and its temperature is elevated. Pain in the tumor 
spontaneously, and on pressure and coughing. The tumor 
gradually disappeared, leaving a cord as thick as catgut which 
was recognized as the spermatic cord. 

An equally rare form is disease of a vas aberrans. Gosselin 
describes the case of a young man in whom, during the third 
week of an acute urethritis, a painful tumor developed in the 
scrotum, as large as a hazel nut and completely free; its 
pedicle could be followed to the neighborhood of the epididymis 
and the origin of the vas deferens. 

Further varieties are created by changes in the position of 
the testis and epididymis. 

These may occur within the scrotum, the mutual relation 
of the testis and epididymis being changed by rotation around 
the horizontal and vertical axes. Royet distinguishes five 
forms : 

1. The epididymis is situated in front of the testis. 

2. It is on the outer or inner side of the testis. 

3. The testis is rotated around a horizontal axis, passing 
from right to left, and the epididymis is situated above the 
testis. 

4. Under the same conditions the epididymis may be situ- 
ated below the testis. 

5. The position of the two organs is subject to constant 
change. 

During a great part of fcetal life the testicle remains in the 
abdominal cavity and descends through the inguinal canal 
into the scrotum at a late period. Now, it may happen that 
the testicle remains in the inguinal canal, or it may go too far 
and pass into the perineum, where it remains on one side of 



Blenorrhcca of the Sexual Organs. 245 

the raphe, or finally it may emerge through the femoral ring 
and remain fixed beneath Poupart's ligament. A testicle 
situated in such an abnormal position may be attacked during 
the course of a blenorrhagic inflammation. 

The most frequent form is intrainguinal epididymitis. MM. 
Robert, Paris and Bouchard have described cases of this kind. 
In mild cases the patient complains of pain in the groin, and 
a painful swelling, covered by reddened skin, appears there, 
but rapidly subsides after rest and antiphlogosis. In severer 
cases the tumor is as large as a hen's egg or goose egg, with 
the long diameter parallel to Poupart's ligament. It consists 
of two distinct parts, one of which is semilunar in shape, situ- 
ated to the outside and below, firm; the other part is situated 
above and within, is oval and elastic, creating almost the im- 
pression of fluctuation. If the spermatic cord forms a loop which 
dips into the scrotum, it is swollen and tender. The inflam- 
mation may also extend to the tunica vaginalis, serous effusion 
forms and presents distinct fluctuation. "When the tunica vag- 
inalis communicates with the abdominal cavity circumscribed 
or general peritonitis may develop. On examination of the cor- 
responding half of the scrotum the testicle is found to be ab- 
sent, and the patient not infrequently tells us that there had 
formerly been an oval swelling in the groin. This variety, like 
subcrural epididymitis, is apt to be mistaken for a bubo, while 
perineal epididymitis may simulate Cowperitis or a periurethral 
abscess. Examination of the scrotum and the demonstration 
of both testicles or the absence of one, form the decisive diag- 
nostic factor. 

A further complication, which was carefully studied by 
Ledouble, is owing to the fact that the corresponding half of 
the scrotum contains a hernia or varicocele in addition to the 
testicle. The tail of the swollen epididymis is apt to adhere 
to the hernia so that the latter becomes irreducible, and the 
inflammation may also extend to the peritoneum of the pro- 
truding gat, giving rise to symptoms of incarceration and peri- 
tonitis. 

The inflamed epididymis may also become adherent to a 
varicocele, causing an exacerbation of the latter. 

Finally, epididymitis may also be complicated by peritonitis, 
which usually remains circumscribed. According to Horwitz 
(1892), who studied this question exhaustively, the peritonitis 



246 BlenorrJicea of the Sexual Organs. 

may develop : 1. As the continuation of an inflammation of 
the vessels of the spermatic plexus to the peritoneal coat of 
the spermatic cord in the pelvis. 2. By inflammation of the 
terminal ampulla of the vas deferens, which extends to the ad- 
jacent Doug-las 7 fold of the peritoneum. 3. By inflammation 
of the lymphatic gland on the internal iliac vein, which re- 
ceives the lymphatics from the vas deferens. A painful cir- 
cumscribed tumor then forms in the pelvis above Poupart's 
ligament and in the region of the posterior inferior spinous 
process. A case of this kind has come under my observation. 

The most favorable termination of epididymitis is recovery. 
Although this takes place in the majority of cases, complete 
restitutio ad integrum is a comparatively rare event. 

It is true that the inflammatory symptoms disappear and 
the swelling diminishes, but the absorption of the infiltration 
is incomplete. In some portion of the epididymis, usually the 
head, a nodule remains, as large as a pea or even larger, firm, 
sharply defined, and causing little annoyance to the patient. 

New injuries occurring during the course of the urethritis 
may be followed by a relapse starting from this nodule, but 
finally the process remains stationary. 

In other cases a diffuse uniform thickening of the head or 
tail of the epididymis remains, and testifies for years to the 
process which has run its course. 

These residua of epididymitis may remain in any part in 
wmich the acute inflammation has been seated. In the vas 
deferens this is shown by the persistence of a firm, painful cord, 
in the tunica A^aginalis by the fact that only a part of the acute 
exudation is absorbed while the rest remains in the form of 
chronic hydrocele. 

A rarer and, naturally, much more serious termination is 
suppuration. Starting from the height of the process, which is 
then extensive and associated with acute hydrocele and eczema 
glabrum, one or more abscesses develop, attended with fever 
and violent pain. The abscesses cause bulging of the skin, 
finally rupture, and discharge crumbly pus. This is attended 
usually with the evacuation of a yellowish, bunched mass, 
which appears to consist of separate threads. When these 
threads are pulled upon, they may be drawn out to a consid- 
erable length. This is the coil of the tubules of the epididy- 
mis. If only one abscess forms and then heals — this is at- 



BlenorrJioea of the Sexual Organs. 247 

tended usually by funnel-shaped retraction of the skin — a 
portion of the epididymis and testis may remain intact. But 
if several abscesses form, the entire contents of one half of the 
scrotum are usually destroyed by purulent degeneration and 
elimination. 

In other cases the process assumes a chronic course after 
perforation externally has occurred. The perforations are 
then converted into fistulous opening's which discharge small 
amounts of crumbly pus, but the destruction continues for a 
very long- time. In this way a large part of the testicle and 
epididymis is eliminated. The integument of the scrotum 
usually becomes thickened by chronic inflammation, its folds 
become very prominent, and hidden between them are the 
fistulous openings, which are often retracted into a funnel 
shape. 

Finally, in tuberculous and syphilitic individuals blenor- 
rhagic epididymitis may furnish the starting-point for the de- 
velopment of corresponding tuberculous and syphilitic changes. 

The course of bilateral epididymitis, which is a rare dis- 
ease, is exactly like that of the unilateral affection. The in- 
flammation rarely develops at the same time on both sides, 
but usually begins in one testicle while the other is recovering. 
It happens not infrequently that after recovery of the former 
the one first affected is again attacked. 

An important question refers to the seminal changes re- 
sulting from disease of the organs which produce and convey 
the semen. These can be better studied in bilateral epidid}^- 
mitis, because in unilateral disease the other side produces 
normal semen. 

In the acute stage, during which pollutions are not uncom- 
mon, the semen is found to have a yellow or yellowish-green 
color from the beginning of the inflammation, and leaves stains 
upon the clothing which have the central gray color of normal 
semen, while there is a yellow ring, like pus, at the periphery. 
In addition to the ordinary cellular elements of the semen mi- 
croscopical examination shows multinuclear pus corpuscles in 
larger or smaller numbers. In unilateral epididymitis sperma- 
tozoa are usually present in large numbers, living and well 
developed, in bilateral epididymitis they are generally absent 
from the second or third day of the disease. In the acute 
stage, after the urethral suppuration has ceased entirely and 



248 Blenorrhcea of the Sexual Organs. 

the urine is clear, the pus which is mixed with the semen can- 
not come from the urinary passages — as may be seen in pollu- 
tions during- the acute stage of a simple anterior urethritis — 
but must be derived from the seminal passages. Fuerbringer 
states that the pus is due to catarrh of these parts. As the 
acute symptoms disappear, the amount of pus in the semen 
diminishes, the latter often becomes peculiarly thin, and the 
spermatozoa often remain absent for several months. This is 
usually associated with diminution of sexual desire. The 
spermatozoa finally return. 

More important, because often permanent, are the changes 
induced by the infiltrations and thickenings which are left 
over. These thickenings, consisting of connective tissue which 
grows constantly firmer, enclose the excretory canals, and 
may thus prevent the passage of semen from the testicle. 
Gosselin's injection experiments have shown that this com- 
pression of the ducts of the epididymis is very often complete, 
but not infrequently consists merely of narrowing of the 
canals. If a fibrous nodule is situated in the head of the epi- 
didymis it is relatively innocuous, because sufficient semen can 
escape through the middle portion and tail. When it is situ- 
ated in the tail the conditions are much more unfavorable, the 
interference is more marked, perhaps even complete. 

If one epididymis alone is diseased, the other performs its 
function regularly, indeed it might be expected to act vicari- 
ously. But this does not happen in all cases. At least Jullien 
states that in the acute stage of certain unilateral epididymi- 
tides, when the other testicle and epididymis appeared to be 
entirely normal, he found complete absence of spermatozoa, 
and that after the disappearance of the inflammatory symp- 
toms he has observed marked oligaspermia, which often lasted 
a long time. 

In 85 cases of bilateral epididymitis, followed by indura- 
tions, Gosselin, Godard, Liegeois and Jullien found only 9 in 
which the spermatozoa returned, in the other 76 cases asper- 
matism remained. It is questionable whether this is permanent. 
At least Horand reports concerning several individuals who, 
although suffering from old bilateral indurations, became 
fathers of a numerous progeny. Gosselin made the interesting 
observation in these cases of aspermatism that the semen re- 
tains its external characteristics, consistence, amount, odor, — 



Blenorrhcea of the Sexual Organs. 249 

facts which are explained by Fuerbringer's investigations on 
the composition of the semen. 

Unilateral suppuration of the testicle does not interfere 
permanently with the function of the other testicle ; the poten- 
tia g*enerandi and coeundi is retained. Bilateral suppuration 
causes impotentia generandi. The ability to perform coitus 
need not suffer, as is shown by Bjoerken's case. A man, set. 
twenty-three years, who lost both testicles in rapid succession 
from suppurating epididymitis, performed coitus and had pol- 
lutions after recovery. The ejaculation did not contain sper- 
matozoa. 

Pathological Anatomy. 

While the relative frequency of this complication and its 
serious significance were the cause of our early knowledge of 
this condition, it also led, on the other hand, to frequent op- 
portunities for anatomical examinations. 

Nevertheless one error was carried down to the beginning 
of the present century, to which the disease owes its popular 
name of " swelled testicle/' The site of the disease was located 
in the testicle, and the affection was called blenorrhagic orchi- 
tis. So far as I know, Monteggia (180-i) was the first to make 
an autopsy in a case of epididymitis, and noted that the testi- 
cle was unaffected. He gives the following description : " The 
tunica vaginalis was adherent to the albiiginea, and a yellow 
purulent fluid was found below between the inflamed and 
thickened membranes. These membranes were more adherent 
than in the normal condition. The membranes of the dartos 
were also hard, thickened and inflamed. The testicle itself 
was normal and not in the least thickened. In that portion 
of the tunica vaginalis which is usually prolonged behind the 
epididymis, was found a cavity containing a soft yellow sub- 
stance, which was probably derived from exuded inflammatory 
lymph. The entire prostate had undergone suppuration and 
was separated into different divisions by a number of pus 
cavities. These abscesses opened into the urethra in three 
places -, twice at the sides of the caput gallinaginis, and also 
further back towards the neck of the bladder. The pus had 
also pushed back the capsule of the prostate and formed a 
large pus cavity between the neck of the bladder and the rec- 
tum." 



250 Blenorrhcea of the Sexual Organs. 

Gaussaille published the reports of two autopsies. In the 
first the epididymis was twice its normal size, firm and hard. 
The testicle also appeared to be doubled in size, but this was 
found, on section, to be due to an accumulation of thick, cloudy, 
slightly bloody serum between the layers of the tunica vagin- 
alis testis. The albuginea was thickened, and traversed by 
dendritic vessels. The substance of the testicle showed no 
notable changes. 

In the second case both vesicular seminales were swollen 
and firm, and the vasa deferentia also showed traces of in- 
flammation. The epididymes were enlarged on both sides and 
of a wine red color, the testicles were normal in size; a small 
amount of fluid in the tunica vaginalis. 

Based on these investigations and on their observations in 
the living, Rochoux and Ricord declared: "Pas deflection 
blenorrhagique des organ es contenus dans les bourses sans en- 
gorgement de l'epididyme," and the truth of this statement is 
generally recognized at the present time. 

Velpeau made an autopsy on a man of twenty-two years 
who died of cholera, and had suffered for eighteen days from 
epididymitis. He found the tunica vaginalis, testicle, and the 
head and body of the epididymis, normal. In the tail was a 
nodule as large as a bean, which was yellow on section. The 
last convolutions of the vas deferens and epididymis appeared 
dilated, and contained pus. No spermatozoa were found in 
the vas deferens and corresponding seminal vesicle. 

In cases of intrainguinal epididymitis Paris found the tunica 
vaginalis adherent to the testicle and covered with false mem- 
branes, the testicle apparently normal, but without seminal 
elements, and usually atrophic. In Gosselin's case the testicle 
was in the inguinal canal, the epididymis had descended into 
the scrotum, was considerably swollen, and infiltrated with 
foci of pus. 

In two cases Godard found the seminal vesicle on the dis- 
eased side smaller than on the other, and there were no sper- 
matozoa in the vas deferens, while they were abundant on the 
healthy side. 

Schepelern reports an interesting case. A sailor, get. seven- 
teen years, who had suffered for three weeks from blenorrhcea, 
and for eight days from left epididymitis, was suddenly at- 
tacked by right-sided peritoneal symptoms and died in thirty- 
six hours. 



Blenorrhoea of the Sexual Organs. 251 

The autopsy showed that the cause of death was typhlitis, 
perforation of the vermiform appendix and peritonitis. 

The urethra was reddened, especially in the most posterior 
portion. The entire left vas deferens was half ag-ain as thick 
as the right, its vessels were injected and tortuous, the cauda 
of the left epididymis was swollen, infiltrated, firmly fibrous, 
and the anterior portion contained a collection of pus as large 
as a pea. The remainder of the epididymis was somewhat 
enlarged, the testicle was normal. In the tunica vaginalis was 
a small quantity of fluid, and beginning adhesive inflammation 
corresponding to the cauda. The tunica propria was thick- 
ened, and adherent to the lower part of the scrotum. Micro- 
scopic examination showed slight catarrh of the vas deferens. 

Finally, we owe to Rougon the history of the following- in- 
teresting case. An artillery officer, get. thirty-five years, is 
brought to the hospital in a dying condition. The skin is cold 
and clammy, the face pinched, the pulse rapid, small and 
thready; pain in the head, thirst, nausea, vomiting* of bile. 
The abdomen tense and painful, especially in the region of the 
right iliac fossa. Eight-sided epididymitis with acute hydro- 
cele of the tunica vaginalis. The autopsy showed : the abdo- 
men distended with gas, ecchymoses in subperitoneal cellular 
tissue on right side. Peritoneum covered with false mem- 
branes, especially in the right iliac fossa; about 300 grm. sero- 
purulent fluid in the iliac fossa and pelvis, 100 gr. sero-purulent 
fluid in the right tunica vaginalis propria testis, the membrane 
injected, and covered here and there with false membranes. 
The right epididymis swollen, reddened, ecchymotic, contain- 
ing spots of pus on section. The right spermatic cord thick- 
ened, with exudation in its coverings. 

The almost complete picture of epididymitis furnished by 
these autopsies is supplemented by the investigations of Malas- 
sez and Terillon. In beginning epididymitis they found the 
epithelium of the seminal canals in a condition of cloudy swell- 
ing and destitute of cilia, the remaining tissues normal. A 
higher grade is characterized by oedema of the walls with 
small cell infiltration. In still more advanced stages the loose 
tissue around the seminal canals is infiltrated and swollen, the 
canals themselves are filled with a yellowish-green fluid, con- 
sisting of semen and pus. The nodules of the advanced stages 
are formed of densely infiltrated connective tissue surrounding 
the seminal canals. 



252 BlenorrJioea of the Sexual Organs, 

Diagnosis, Prognosis. 

The symptomatology is so characteristic that there can 
hardly be any doubt concerning- the nature of the affection in 
the majority of cases. In cases of abnormal position the 
knowledge of this fact, together with examination of the scro- 
tum, which should never be neglected, as regards the presence 
of both testicles, suffice for the diagnosis. 

The prognosis is favorable in the majority of cases. The 
possibility of suppuration or peritonitis should make us cautious 
in giving a prognosis in feeble, cachectic individuals, or when 
the inflammatory phenomena are very severe. 

Treatment. 

Unlike the changing principles of treatment of gonorrhoea 
and its complications, the treatment of epididymitis has re- 
mained tolerably stable. The methods varied only between 
the limits of antiphlogistic treatment. The first thought 
would be to diminish the swelling or prevent its increase by 
exercising external compression, and so this plan was adopted 
after that of abstraction of blood, which was so prevalent at 
the beginning of the century. The oldest of these methods 
is that of Fricke, who performed compression by means of 
strips of adhesive plaster. The testicle and epididymis of 
the diseased side were first grasped separately in the corre- 
sponding half of the scrotum and prevented from slipping by 
an encircling strip which compressed the scrotum immediately 
above them. Then follows a series of vertical strips, about 
the width of the finger and overlapping like shingles, which 
cross at the lower extremity of the scrotum, and thus form a 
firmly adherent cap. These are secured by one or more en- 
circling strips. Employed originally in recent epididymitis, 
this method, which is still used occasionally, is confined gener- 
ally to the second stage when the inflammatory S3^mptoms 
have disappeared and the swelling alone remains. This dress- 
ing aids resorption materially, but it possesses the disadvan- 
tage that, when applied too tightly, it produces pain or causes 
atrophy of the testicle, and when applied loosely, has little 
effect and must be frequently changed. This is painful, be- 
cause the dressing adheres firmly to the hairs on the scrotum. 



BUnorrhcca of the Sexual Organs. 



253 



White's dressing is a modification of Fricke's. Miliano's com- 
pressing 1 suspensorj 7 (Fig. 35) acts in a similar manner, though 
not so brusquely. It consists of a knitted sac, fitting one half 
the scrotum, provided with straps, the tightening of which 
enables us to produce moderate compression of the testicle 
and epididymis. 

A series of applications to the scrotum also produce com- 
pression. These are usually of an irritating or caustic nature, 




Fig. 34. 

and cause compression by means of reflex contraction of the 
tunica dartos. These include the application of nitric acid, 
collodion, concentrated solutions of nitrate of silver (1 : 20), sul- 
phuric ether, and tincture of iodine. 

The diminution of the tension was also regarded as anti- 
phlogistic, especially in those cases in which fluid had accumu- 
lated in the tunica vaginalis. Velpeau recommended puncture 
of the tunica vaginalis with a bistoury for this purpose. This 
is a harmless method, which usually produces immediate relief, 
but is followed unfortunately by a fresh accumulation of fluid. 



254 



Blenorrhcea of the Sexual Organs. 



Vidal recommended a more vigorous plan, viz., debride- 
ment, or splitting- of the covering's of the testicle down to the 
tunica vaginalis over an extent of 1.5 to 2.0 cm. This treat- 
ment was abandoned after several cases were reported in 
which it had been followed by suppuration, gangrene, and 
elimination of the testicle. In recent times Smith, Ragazzoni, 




Fig. 35. 



Appiani, and Nunn have again recommended punctures, partly 
simple, partly extending to the tunica vaginalis. Jobert 
injects several drops of tincture of iodine into the tunica vagi- 
nalis. 

Watson Spencer follows puncture with an adhesive-plaster 
dressing. Bonniere scarifies, applies ice compresses and, when 
the integument of the scrotum has contracted, a knitted, snugly 
fitting suspensory, which is smeared with rapidly drying glue 
in order to make it more resisting. 



Blenorrhoea . of the Sexual Organs 255 

Cold has also been applied locally in the shape of cold com- 
presses and ice. This is an extremely vigorous antiphlogistic, 
but the continued application of ice gives rise to extremely 
firm infiltrations, which then resist absorbent treatment for a 
long time. 

All these cumbersome apparatus are generally abandoned 
at the present time. The conviction has been reached that 
epididymitis runs a favorable course spontaneously, and that 
in the majority of cases it is merely the duty of the physician 
to keep hurtful factors at a distance. Rest in bed, and an ele- 
vated, guarded position of the scrotum by placing beneath it 
a compress or handkerchief, suffice to diminish the pains and 
secure a favorable termination. Regular evacuations from 
the bowels and fever diet will do the rest. The pollutions are 
treated in the usual way. Frequently changed compresses of 
cold water are useful, but ice compresses must not be em- 
ployed. If we are anxious to do something more, unguentum 
cinereum with extr. belladonna (1 : 25) may be applied ex- 
ternally. Under this treatment the inflammatory symptoms 
disappear in four to five days. 

Few patients are able to remain in bed during the inflam- 
matory stage of epididymitis, as this is rendered impossible by 
the necessary secrecy. The application of Horand-Langiebert's 
suspensory (Fig. 36) then offers an admirable substitute for the, 
in great part, expectant plan of treatment just described. 
This consists of a thick layer of cotton, in which the entire 
scrotum is carefully enclosed; over this comes a piece of rubber 
cloth suitably cut out, and then a wide linen suspensory, like 
the ordinary varieties, except that it possesses two lateral 
gores which are closed by bands. This permits better fitting 
of the suspensory, especially to the perineum, and enables us 
to cover the scrotum completely. This apparatus protects 
the epididymis from external injuries, fixes it and keeps a uni- 
form warm temperature, conditions which correspond to those 
of rest in bed. 

In fact this suspensory has an admirable effect. Patients 
who could hardly walk on account of the violent pains, ex- 
perience decided relief immediately after its application and 
can usually attend to business at once. It is only in cases of 
considerable swelling of the spermatic cord that the suspen- 
sory is not well borne. If it is well borne, it should be worn 



256 



Blenorrhoea of the Sexual Organs. 



constantly for several days, the cotton being* renewed every 
twenty-four hours. The bands, which are drawn as tightly 
as possible during- the day, are loosened at night. 

Under this plan the inflammatory symptoms also disap- 
pear in four or five days, and a second important indication 
must then be fulfilled, viz., the absorption of the infiltration. 
Moist heat, and iodine internally and externally, give good 
results. Those patients who have worn Langlebert's sus- 
pensory continue its use, those who have remained in bed 




Fig. 36. 

wear this or some other wide and comfortable suspensory, 
which will contain the necessary dressings. We recommend 
a dressing of moist linen, folded three or four times, over this 
a piece of parchment or g-utta-percha paper, projecting slightly 
beyond the edges of the linen, and then a tolerably thick layer 
of cotton. The suspensory is then applied over the cotton. 
The linen is moistened two or three times a day. If the patient 
has already worn a Langlebert's suspensory, the form of dress- 
ing may be changed as soon as the pain disappears. When 
the inflammatory symptoms have been treated with cold, it is 



Blenorrhcea of the Sexual Organs. 257 

well to allow an interval of twenty-four hours between the 
change from cold to warmth, or the change may be made 
gradually by allowing the cold compresses to remain until 
they begin to grow warm, as soon as the inflammation sub- 
sides. Unless some injury intervenes (coitus, excessive exer- 
cise, pollutions, etc.), this treatment causes rapid and thorough 
removal of the infiltration. If the infiltration is old and firm 
iodine may be used. The following ointment is rubbed in be- 
neath the damp linen on the diseased side : 

$ Potass, iodid., . gr. xxx. 

Iodin. p., gr. iij. 

Lanolin., 3 v. 

01. olivar., 3 ss. 

This is used twice a day, and gr. xv.-xxx. of potassium iodide 
are given internally pro die. Unfortunately this treatment 
can only be adopted intermittently on account of the eczema 
which usually develops on the scrotum ; when the skin itches 
and reddens, rice powder must be applied at once. Very old 
infiltrations and nodules, even if they have lasted for years, usu- 
ally are absorbed, at least in part, when treated in this way. 

Inasmuch as epididymitis is the result of a posterior urethri- 
tis, the latter must always be subjected to treatment after the 
recovery of the former. This may be done even while the 
painless infiltration is being treated in the manner described 
above. But the acute inflammatory symptoms must have 
disappeared for several days, as they are apt to return on 
premature beginning of treatment. 

I can especially recommend Diday's irrigation of the pars 
posterior as the mildest method. 

After the recovery of the epididymitis it is wrong to treat 
the blenorrhoea, which usually returns, with the gonorrheal 
syringe. We have already spoken of its uselessness in pos- 
terior urethritis. On the other hand I could never convince 
myself of the spontaneous recovery of posterior urethritis in 
these cases, but am satisfied that severe symptoms follow if it 
is neglected and allowed to pass into the chronic stage. 
17 



258 Blenorrhosa of the Sexual Organs. 



VI. INFLAMMATION OF THE SEMINAL VESICLES. 

Our knowledge of this rare complication of clap is very 
defective, so that I must content myself with its aphoristic 
description. 

1. Acute sperm at ocystitis, according" to Pitha, usually at- 
tacks one, more rarely both seminal vesicles at the same time. 
Rectal examination shows on the corresponding side of the 
posterior wall of the bladder, immediately over the prostate, 
a pear-shaped, firm or fluctuating swelling, which is much 
larger than the normal seminal vesicle, is painful and warm. 

The symptoms consist of dull pressure in the rectum, which 
radiates towards the sacrum and bladder, and is notably in- 
creased on defecation, while micturition is usually undisturbed, 
though sometimes painful. There is usually violent sexual ex- 
citement, manifested by priapistic erections. Pollutions are 
very frequent, but are accompanied by violent burning pains, 
especially at the moment of ejaculation, instead of a feeling of 
pleasure. The ejaculated fluid has a yellow, red or brownish- 
red color, and leaves stains on the clothing, which are gray 
in the centre and surrounded by a yellow and brownish-red 
ring. The microscope shows blood, pus, and either no sperma- 
tozoa or dead ones. The patients are usually very depressed 
or irritable and anxious; this is partly due to the priapistic 
painful erections and frequent pollutions. The blenorrhagic 
discharge either ceases or it is abundant. In the- latter event 
it contains spermatozoa. There may be high fever for a long 
time. Suppuration of the seminal vesicles, with discharge of 
the pus into the. intestines and recovery, and into the perito- 
neal cavity with fatal termination, has been observed. On 
passing into the chronic stage the inflammatory and painful 
symptoms disappear, but the pollutions may continue, the 
semen constantly growing thinner and more albuminoid. As 
in spermatorrhoea, defecation causes the discharge of thick, 
lumpy, paste-like masses. 

2. Chronic spermatocystitis develops in part from the acute 
form, in part directly as a complication of chronic urethritis. 

Its symptoms are very obscure. Humphrey noted violent 
irritative symptoms on the part of the bladder, and incon- 
tinence. In one case I found that both seminal vesicles could 



Blenorrhcea of the Sexual Organs. 259 

be felt per anum as firm, indurated, pyriform, painless nodules; 
despite continence there were extremely few pollutions, the 
product of which was pus and mucus corpuscles, with a few 
dead spermatozoa. In another case the very frequent and 
painless pollutions ejaculated a chocolate -brown mass, the 
color of which was due to decomposed blood; it contained pus 
and mucus corpuscles but no spermatozoa. 

Post-mortem examinations are very scanty. Gaussaille 
and Hardy found, in acute vesiculitis, that the seminal vesicles 
were dilated by a thick, whitish-yellow mass, consisting- of 
semen and pus ; the lining" membrane of the vesicles was in- 
jected, their walls firm. In chronic cases Lallemand and 
Humphrey found the ducts of the seminal vesicle dilated, the 
walls thickened, even cartilaginous or bony. 

On account of the rarity of the disease the treatment is 
very meagre. A plan like that adopted in prostatitis may be 
recommended. In two cases of chronic vesiculitis I have ob- 
tained good results from my apparatus, which I mentioned in 
discussing the treatment of prostatitis, in conjunction with 
the previously mentioned potassium iodide-iodine suppositories. 

VII. INFLAMMATION OF THE BLADDER. 

General Remarks. 

Cystitis was formerly regarded as one of the most frequent 
complications of urethral g-onorrhoea, and this opinion has 
been held even in recent times. The latest investigations, 
however, have materially modified this opinion. The diagnosis 
of blenorrhagic cystitis is often made at the present time, but 
usually without justification. Under this diagnosis are usually 
included three processes, whose accurate differentiation we 
have learned very recently. These are : 

Acute posterior urethritis, — i.e., inflammation of the 
membranous and prostatic portions, which terminates at the 
internal prostatic sphincter and leaves the bladder intact. 

Cystitis, — either a total or partial inflammation of the vesi- 
cal mucous membrane; it may be localized in different parts, 
but is usually situated either at the internal orifice of the 
urethra or the fundus of the bladder. 

Acute posterior urethritis with partial inflammation of 
the bladder, around the internal orifice of the urethra and 
at the trigonum Lieutaudii. 



260 BlenorrJioea of the Sexual Organs. 

Pure and uncomplicated posterior urethritis is the most 
frequent of these three varieties. Next in frequency comes 
the last-mentioned form, in which the process extends from 
the pars posterior to the adjoining- mucous membrane of the 
bladder, to the vicinity of the internal orifice of the urethra. 
This is generally described as " cystite du col/' or catarrh of 
the neck of the bladder, but I would discard the term " neck 
of the bladder/' as it has no anatomical foundation. If by 
this term we mean only the pars posterior, the expression 
may be more precise but is superfluous. If the term is also 
meant to include the adjacent part of the bladder, it becomes 
vague. In the empty as well as the moderately full condition 
the bladder realty has no neck, and is separated sharply from 
the urethra by the internal prostatic muscle. It is only in ex- 
cessive distention of the bladder, i.e., when it is really no 
longer in a normal condition, that a neck is formed, a reserve 
reservoir for urine in the posterior portion of the urethra, But 
this furnishes no reason for an anatomical description of the 
normal bladder based on a condition which is temporary and 
is always associated with discomfort. I will therefore eschew 
the term neck of the bladder, and propose the term posterior 
urethrocystitis for this form of disease. Finally, the rarest 
cases are those of pure cystitis. It usually develops from a 
posterior urethrocystitis, very rarely directly, inasmuch as the 
initial symptoms of posterior urethritis disappear rapidly or 
are barely marked. 

With regard to the etiology of the cystitis, it is questiona- 
ble whether it constitutes a direct blenorrhagic affection or is 
to be regarded as a mixed infection, due to the intervention of 
other irritants. Bumm maintains that every cystitis in the 
female is produced by a mixed infection, and this is also very 
plausible with regard to males. The urine of the bladder, in 
every case of cystitis, contains numbers of cocci and bacteria, 
while a large number of gonococci, from which we might infer 
proliferation in the bladder, cannot be demonstrated. The 
gonococci, if present at all, are always found in small numbers. 

In a case of blenorrhagic cystitis in which an autopsy was 
obtained, Du Mesnil (1891) was unable to find gonococci in the 
secretion or upon the surface of the vesical mucous membrane. 
He also proved that gonococci do not decompose urea, so that 
alkaline and ammoniacal cystitides, which complicate blenor- 
rhoea, cannot be due to this coccus. 



Blenorrhcea of the Sexual Organs. 261 

Symptomatology. 

Posterior Urethro-cystitis. — The symptoms are a mixture 
of those of posterior urethritis and cystitis. As a rule, the 
subjective symptoms are due to the former, while the latter 
is manifested by objective symptoms alone. With regard to 
the subjective symptoms I may refer to the article on posterior 
urethritis. There is usually tenesmus, almost constant in 
acute cases, while in subacute cases it is only imperative when 
the bladder is full. In addition there are radiating- pains along 
the urethra, burning and tenesmus after micturition. In the 
subacute cases is also found another symptom to which I was 
the first (1880) to call attention. This is the variation in the 
tenesmus according to the position of the patient. So long as 
he stands and walks the tenesmus is more frequent and im- 
perative than when the recumbent position is assumed. In 
the erect position the urine accumulates upon the inflamed 
portions of the vesical orifice and surrounding parts, which it 
irritates by its weight and thus increases the tenesmus, while 
in the recumbent position the bladder sinks down and the 
urine is received in the fundus. 

Among the objective symptoms the discharge of blood with 
the last drops of urine is dependent on the acute posterior 
urethritis. 

In the test of the two beakers the urine is found cloudy in 
both. But there are some material differences from -simple 
posterior urethritis. In acute posterior urethritis the second 
urine, although cloudy, is always clearer than the first, and 
second clear portions alternate with cloudy ones. We have 
already explained the reason of this phenomenon. 

In acute posterior urethro-cystitis the cloudiness of the 
urine in the bladder is the result of two factors, viz., the 
muco-pus which enters the bladder from the pars posterior, 
and then the muco-pus which is formed in the bladder by the 
catarrhal mucous membrane. It therefore follows that : 

Inasmuch as the cloudiness is produced in the bladder itself, 
a second clear urine is never observed. 

In posterior urethritis the cloudiness of the first urine is 
caused by the pus in the urethra, while the second urine is 
cloudy from the excess of pus which has passed from the pars 
posterior into the bladder. In urethro-cystitis the urine is 



262 Blenorrhcea of the Sexual Organs. 

clouded in the bladder by the pus and mucus produced there. 
In the latter disease, therefore, the cloudiness of the urine in 
both vessels is more pronounced, the difference between both 
portions is not considerable, because the muco-pus will be pre- 
cipitated in the bladder and will escape with the last urine. 

If a patient with acute posterior urethrocystitis is allowed 
to urinate in three portions, the first will be very cloudy from 
the excess of muco-pus in the urethra ; the second is less cloudy, 
containing' the upper layers of urine from the bladder which 
flow through a clean urethra; the third portion is again more 
cloudy, because it washes away the muco-pus produced in the 
bladder and which has been partly precipitated. Some patients 
notice that with or after the last drops of urine pure pus es- 
capes from the urethra in a few drops or a short stream. 

If this urine is allowed to precipitate in two or three por- 
tions, we usually find the two well-known layers, a lower, 
rapidly precipitating, crumbly layer of pus : an upper, loose, 
slowly precipitating, cloudy or flocculent layer of mucus ; above 
this clear urine. The relative proportions of both layers vary, 
whence we may distinguish a more mucous or more purulent 
catarrh. 

The microscopical examination shows pus and mucus cor- 
puscles, large flat epithelium of the bladder, and variously 
formed epithelial cells, which are derived partly from the lower 
layers of the bladder, partly from the urethra. In the first 
urine we often find quite numerous gonococci in the pus cells; 
in the second urine pus cells containing gonococci are scanty 
or absent, while there is often an abundance of other cocci and 
many short rods, not in cells. 

Chemical examination constantly shows a small amount 
of albumin; when the tenesmus is violent it often persists as 
long as the latter, may become very considerable, and is pro- 
duced by the tenesmus. 

The reaction of the urine is usually acid, rarely alkaline. 
The latter reaction is generally due to haematuria. If the 
posterior urethritis is very acute, blood not alone appears with 
the last drops of urine, but the hemorrhage from the pars pos- 
terior, excited by the violent tenesmus, is abundant and pro- 
tracted. The blood which escapes from the pars posterior in 
the intervals between micturition, enters the bladder and may 
neutralize the acid reaction of the urine accumulated there or 
make it alkaline. 



Blenorrhcea of the Sexual Organs. 263 

In making* the test of the three beakers the urine is then 
found bloody in all. In the third glass, the muco-pus, mixed 
with blood, appears as a tough, snotty mass which adheres to 
the vessel, and under the microscope shows variously shaped, 
in part destroyed, blood and pus corpuscles, epithelium and 
the well-known coffin-lid triple phosphate crystals. The urine 
is foul smelling and filled with micro-organisms. The amount 
of albumin is large, probably dependent on the presence of 
blood. 

It is hardly to be supposed that in these cases the inflam- 
mation of the bladder is confined to the vicinity of the vesical 
orifice, but it probably affects the entire mucous membrane. 
In addition to the symptoms mentioned there is often violent 
pain over the symphysis, which increases on pressure, and 
slight paresis of the detrusors. The bladder, despite frequent 
micturition, remains half filled and can be felt above the sym- 
physis. If the acute posterior urethritis subsides, the tenes- 
mus and haematuria disappear, while the symptoms of acute 
purulent cystitis remain and not infrequently become chronic. 

Acute Cystitis. — This is a rare complication of acute ure- 
thritis. It very rarely happens that an acute anterior urethritis 
extends unnoticed to the pars posterior and then gives rise to 
cystitis. The acuteness of the inflammatory symptoms on the 
part of the pars posterior almost always provokes, in such 
cases, an acute posterior urethrocystitis. More frequent are 
cystitides resulting from subacute and chronic posterior ure- 
thritis, which extends to the bladder as the result of the well- 
known local or remote irritants. Cystitis also develops as the 
residuum of an acute urethrocystitis when the symptoms of 
acute posterior urethritis have disappeared. In these cases 
the acute cystitis usually produces few subjective symptoms. 
General malaise, the result of slight fever, pain over the sym- 
physis and moderate tenesmus are the only symptoms. 

The test of the two or three beakers always shows most 
marked cloudiness of the second or third vessel, because this 
depends on the muco-pus produced in the bladder and which 
has been, in part, precipitated. 

We may distinguish two grades of this disease : 

Mucous, Catarrhal Cystitis. — The urine is acid, slightly 
cloudy, precipitates slowly. The sediment is flocculent, con- 
sists of numerous mucus corpuscles, large bladder epithelium 
and micro-org-anisms. 



264 Blenorrhcea of the Sexual Organs. 

Purulent Cystitis. — The cloudiness of the urine is more 
marked, its reaction neutral or more frequently alkaline. The 
sediment is white and crumbly, and precipitates rapidly ; or, if 
the reaction is alkaline, it is snotty and lumpy, yellow or 
greenish. The microscope shows numerous pus corpuscles 
and, if the reaction is alkaline, abundant coffin-lid crystals of 
the triple phophates. Numerous micro-organisms and bladder 
epithelium are always found. When the reaction is alkaline 
the urine is always very foul smelling. The amount of albu- 
min is proportionate to that of pus. 

Chronic Cystitis. — This develops very rarely directly from 
chronic posterior urethritis and prostatitis, more often it de- 
velops from acute cystitis. Here also we may distinguish 
mucous and purulent catarrh. The objective symptoms just 
mentioned become permanent and often contrast in a very 
striking- manner with the absence of all subjective symptoms. 

The causes of the spread of the inflammation to the bladder 
are the well-known intercurrent morbific agents which operate 
during the course of urethritis. Some of these are particularly 
adapted to the production of cystitis. Thus, excesses in venere 
or Baccho, during the course of acute posterior urethritis, give 
rise much more often, indeed almost without exception, to epi- 
didymitis. The development of urethrocystitis or cystitis, 
on the other hand, is usually the result of direct local irrita- 
tion, instrumental examination or strong injections. This fact 
favors the view that cystitis is the result of other irritants 
which have been introduced in this way, as was directly ob- 
served in PaillarcVs previously mentioned case. 

As a rule, acute anterior urethritis is first followed by a 
posterior urethritis, and this by cystitis, or the anterior ure- 
thritis is followed directly by posterior urethrocystitis, which 
remains in an acute or subacute stage for a few days, and then 
g-enerally disappears rapidly. 

But the symptoms of urethritis may disappear first, those 
of cystitis then predominate for some time, and finally these 
also recover. Finally, the cystitis may pass into a chronic 
stage. These are the most frequent terminations. A rarely 
observed termination is that of the spread of the inflamma- 
tion to the other layers of the bladder, and the development 
of parenchymatous cystitis. This is always a dangerous dis- 
ease. Ulceration of the bladder and perforation, with fatal 



BlenorrJicea of tJie Sexual Organs. 265 

peritonitis, may set in, as in Gintrac's case. The inflammation 
may also spread outwards layer by layer without ulceration, 
extend to the peritoneum and be followed by purulent peri- 
tonitis and death, as in Gendrin's previously quoted case. 

Finally, another rare eventuality is the extension of the 
inflammatory process to the renal pelvis and the kidney. 

Diagnosis and Differential Diagnosis. 

The diagnosis of posterior urethrocystitis, acute and 
chronic cystitis, is evident from the symptomatology just de- 
scribed. Acute posterior urethritis must be differentiated 
from posterior urethro-cystitis and acute cystitis. A con- 
sideration of their individual symptoms, especially testing* the 
urine in two or, if necessary, three vessels will usually enable 
us to make the diagnosis without difficulty. Nevertheless 
there are cases, generally of a subacute character, in which in 
addition to the symptoms of subacute posterior urethritis, 
there is uniform cloudiness of the urine in both vessels or even 
in all three, and it is not easily settled whether we have to 
deal with a pure posterior urethritis or an urethro-cystitis. If 
other methods of examination have given no sufficiently de- 
cided result, the following plan is recommended. A narrow 
elastic catheter is introduced into the bladder, the organ 
washed out with lukewarm water, and the catheter, which is 
kept closed, allowed to remain. At the end of an hour the 
urine accumulated in the bladder is discharged through the 
catheter. If this urine is clear the implication of the bladder 
in the inflammatory process is excluded. 

I must also make mention of phosphaturia, which, to the 
superficial observer, presents a picture similar to that of cys- 
titis. The fact that both processes are often confounded 
proves the routine manner of ordinary examinations, and that 
the diagnosis of cystitis is often made from mere cloudiness of 
the second urine. In order to avoid error we recommend 
Ultzmann's simple method, which is easily made at each ex- 
amination. A test tube of the cloudy urine is slowly heated 
to the boiling point. If the cloudiness disappears, it consists 
of urates. If it becomes more pronounced, a few drops of 
acetic acid are added. If it then disappears, it consists of 
earthy phosphates; if unchanged, it is due to pus. Finally, if 



266 Blenorrhcsa of the Sexual Organs. 

the cloudiness remains unchanged on boiling* and the addition 
of acetic acid, it is composed of pus or bacteria, and the dis- 
tinction is shown under the microscope. 



Pathological Anatomy. 

The number of autopsies on blenorrhagic cystitis is small. 
The few known ones, such as those of Gendrin and Gintrac, 
disclosed very marked changes, which are not found in the 
majority of cases. Thus, in Gendrin's case, the bladder was 
smaller than normal, its walls rigid and thickened, its contents 
sanguino-purulent. The mucous membrane, considerably thick- 
ened, was covered with a thick layer of tough muco-pus, and 
showed several ulcerations of different sizes. The peritoneum, 
especially at the fundus of the bladder, had a wine-red color 
and was covered with firmly adherent membranes. In Mur- 
chinson's case the mucous membrane of the bladder was thick- 
ened, reddened and covered with pus. 

Examination of the bladder with the endoscope, which I 
adopted in 1879 in association with Nitze, furnishes us clear 
data concerning the ordinary changes in the mild and more 
frequent cases. According to the severity and extent of the 
process the bladder is found more or less ridged in toto or in 
places, more or less reddened or traversed by dendritic vessels. 
The epithelium is lifted from its base, and loosened in shreds, 
which in part are still adherent to the mucous membrane by 
thin threads, in part float free in the urine, while the swollen 
follicles project as dark red points. 

Burckhardt (1889) made an endoscopic study of the changes 
in posterior urethro-cystitis. In the usual, uncomplicated 
forms he finds the mucous membrane of the pars prostatica 
of a dark-red to bluish-red color, with a velvety or ridged 
condition of the surface. When the ridging is marked the 
radial stripes are not visible. The mucous membrane bleeds 
readily on contact with the tampon. The colliculus is usually 
swollen and dark in color. The mucous membrane in the 
vicinity of the internal orifice and extending to the trigonum 
has a very red color, but no vessels are distinctly visible. 
This diffuse redness rapidly gives place to the lighter normal 
color, without the intervention of a transition zone. 



BlenorrJioea of the Sexual Organs. 267 



Prognosis. 

As in all complications of blenorrhcea the prognosis should 
not he made absolutely favorable. In the first place, cases 
have been known, though rarely, to have a bad or even fatal 
termination, and, in the second place, all complications, includ- 
ing 1 cystitis, have a tendency to pass into an obstinate chronic 
stage. Nor must it be forgotten that a complication creates 
a striking predisposition to its redevelopment on fresh infec- 
tion, and that the obstinacy of the affection always increases 
on its recurrence. 

Treatment. 

The indications for treatment vary according to the in- 
tensity and acuteness of the process. In acute urethrocystitis 
and cystitis the treatment is chiefly symptomatic and expect- 
ant. Regulation of hygienic and dietetic measures often suf- 
fices to effect rapid recovery of the affection. Above all rest in 
bed is necessary, and the patients readily yield to this instruc- 
tion, inasmuch as cystitis is always regarded by them as a 
dangerous disease. In addition we order fever diet, and regu- 
late the bowels. The following decoctions are ordered as 
drinks : 

I£ Decoct, fol. uvse ursi, % xvj. 

Syr. diacodi., § ss. 

S. One tablespoonful every two hours. 

^ Decoct, semin. lini., § xvj. 

Tinct. opii, gtt. xv. 

Aq. laurocerasi, . . . . .3 iiss. 

S. One tablespoonful every hour. 

3 Herb, herniarige, 

Fol. uvae ursi, aa § j. 

S. Made into a tea. One cupful morning and evening. 

^ Herb, herniar., 

Herb, chenopod. ambros., . . . aa § j. 
S. To be made into a tea. 

If the haematuria is marked, styptics are given internally, 
for example : 



268 Blenoi-rhcea of the Sexual Organs. 

B Ferri sesquichlorid. sol., .... gtt. xv. 

Aq. destil., % v. 

Syr. amant. cort., 3 vj. 

S. One tablespoonful every hour. 

Painful symptoms are treated with suppositories of extract 
of belladonna and morphine, or subcutaneous injections of 
morphine. Opium is to be avoided, as it is apt to produce con- 
stipation. Warm abdominal compresses are the simplest 
remedy in pain, tenesmus and dysuria; when these are more 
severe, morphine is indicated. 

Causal treatment is only adopted after all irritative symp- 
toms have disappeared and the objective symptoms still con- 
tinue. 

This treatment must first be internal. 

The well-known balsams (oil of sandal wood, copaiba, tur- 
pentine), prescribed as in urethritis, often produce good effects 
and cause the urine to clear up rapidly. If they are not well 
tolerated or do not produce the desired effect, we may pre- 
scribe : 

^ Tannin, gr. xv. 

Camphor ras., gr. iss. 

Sacch. alb., 3 ss. 

Inf. pulv. Div. in dos. X. 
S. Three powders daily. 

^ Extr. cannabis ind., 

Extr. hyoscyami, aa gr. v. 

Sacch. alb gr. lxxv. 

M. f. pulv. Div. in dos. X. 

S. Three to five powders daily. 

B Acid benzoic, gr. lxxv. 

Aq. destil., 5 x. 

Syr. cort. amant., 3 vj. 

S. One tablespoonful every two hours. 

^ Extr. cannabis ind., gr. v. 

Sacch. alb., gr. lxxv. 

M. f. pulv. Div. in dos. X. 

S. Three to five powders daily. 



Blcnorrhvea of the Sexual Organs. 



269 



fy Soda salicyl., 

M. f. pulv. Div. in dos. X. 

S. Three powders daily (in wafers). 

1£ Potass, chlorat., . 

Aq. laurocer., . . . 

Aq. destil., 

S. To be taken in one day (caution!) 



3 hss. 



gr. xlv.-lxxv. 

3 ss. 
5 x. 



Alkaline waters are to be used cautiously. So long- as the 
affection is a mild, mucous, catarrhal process, and the urine is 
distinctly acid, the waters of Preblau, Griesshuebl, Gleichen- 
berg, and Wildungen often have rapid and good effects. But 
if the urine is feebly acid or alkaline, and there is a ten- 
dency to phosphaturia, these waters are directly contra-indi- 
cated. They increase the alkalinity of the urine and the phos- 
phaturia and keep up the process, while it should always be 
our object to increase the acidity of the urine. The above- 
mentioned remedies, the balsams, tannin, salicylate of soda 
and benzoic acid are especially adapted to this purpose. But 
it often happens that, although the irritative symptoms dis- 
appear, these internal remedies do not prove successful. The 
urine remains cloudy and continues to contain pus and mucus. 
Local treatment is indicated in these cases. In addition to or 
apart from the internal treatment, we proceed to wash out 
the bladder with medicated solutions. These irrigations are 
best performed by first introducing an elastic, not too large 
catheter, into the moderately full bladder and evacuating the 
urine. We next inject, by means of a syringe, containing 6 
to 10 ounces, one or two syringefuls of lukewarm water into 
the bladder, allow it to escape at once, and then one of the fol- 
lowing solutions, after it has been warmed : 



fy Acid salicylic, 


gr. xv. 


Aq. destil., 


. . . Ivj. 


5 Resorcin, 


gr. xlv.-lxxv 


Aq. destil., 


. I iij. 


^ Quininae sulph., 


. gr.vij. 


Aq. destil., 


. 5 adj. 


I£ Potass, hypermang., 


gr. iss. 


Aq. destil., 


■ §y> 



270 BlenorrJioea of the Sexual Organs. 

^ Acid boric, ....... gr. xlv. 

Aq. destil., 3 vj. 

5 Argent, nitric, gr. vij.-xv. 

Aq. destil., 3 xv. 

These solutions are allowed to remain in the bladder for 
three to five minutes, then removed and water injected, unless 
we prefer to allow the solution to remain in the organ. 

In chronic cystitis tonic regimen is indicated, in addition to 
local and internal treatment. Many chronic cystitides, kept 
up by nutritive disturbances or cachexia, are only cured after 
recovery of the latter. 

VIII. INFLAMMATION OF THE RENAL PELVIS AND 

KIDNEY. 

This rare complication of acute urethritis is also the least 
known. The diagnosis of blenorrhagic pyelitis is made not in- 
frequently, but usually improperly. If a patient with acute 
blenorrhoea suffers, in addition to violent tenesmus and the 
symptoms of acute urethro -cystitis, from pain in one or both 
loins, fever and perhaps chilliness, if the examination of the 
urine shows a larg-er amount of albumin than is accounted for 
by the amount of pus, pyelitis is commonly diagnosed. This 
diagnosis is erroneous. In cases of violent tenesmus the large 
amount of albumin results from this symptom, as can be very 
easily proven. If the tenesmus is ameliorated the amount of 
albumin diminishes at once and corresponds to the amount of 
pus, and increases at once with the increase in the tenesmus. 

We must reserve the diagnosis for those cases in which the 
amount of albumin is larger than that of pus, apart from the 
tenesmus, and the microscope shows casts and epithelium of 
the straight urinary tubules in the sediment. Such cases 
occur and have been reported by Vidal, Rosenstein, Zeissl and 
myself. Murchinson performed an autopsy on a case of sup- 
purative pyelo-nephritis. Fuerbringer (1890) observed several 
cases in which, after an attack of cystitis, chills and fever 
developed, with polyuria, pain and tenderness in the region 
of one kidney, vomiting and headache. The diagnosis was 
confirmed by the finding of casts of the renal pelvis. All the 
cases lasted only a few days and terminated spontane- 
ously. In one case the cystitis and urethritis recovered 
with the pyelitis; but these cases are so rare and their origin 
so obscure that I must confine myself to these brief remarks. 



CHAPTER V. 

BLENORRHCEA IN THE FEMALE. 

General Remarks. 

As we know from the historical section of this work, 
blenorrhcea of the female has long- been recognized, but the 
recognition of its true nature, mode of spread, and importance, 
is a late development. 

This is the result of two factors. In the first place, the 
ignorance of the symptoms and localizations of subacute and 
chronic blenorrhcea, so that many women who suffered from 
blenorrhcea appeared to be healthy. Furthermore, catarrhs 
which are clinically indistinguishable from the blenorrhagic 
process may develop in women from other causes, such as 
fibroids, uterine polypi, etc. This circumstance led to the 
avirulistic theory, viz., that coitus with a healthy, i.e., non- 
blenorrhagic female may give rise to clap under special cir- 
cumstances. 

The considerations previously mentioned, and particularly 
the fact that the most careful attention to Ricord's prescrip- 
tion does not produce clap in married life, led to the viru- 
listic theory, to the conviction that the woman from whom a 
man acquired clap must also suffer from the same disease. 

But this did not increase our knowledge of blenorrhagic 
diseases in women. I still remember when it was impossible 
for me to demonstrate a trace of Menorrhagia on examining 
a woman from whom a man was proven to have acquired 
acute gonorrhoea. Not alone could the diagnosis not be made 
in many cases, but the severity of the process in women was 
not recognized. The knowledge of the process was confined 
to the recognition of vaginitis, vulvitis, abscess of Bartholin's 
glands, and urethritis. The latter was regarded as very rare 
(five per cent, of all blenorrhagic females, Zeissl). Very bold 
syphilidologists ventured to speak of an " endometritis cervi- 
calis blenorrha erica.'" 



272 Blenorrhoca ?f the Sexual Organs. 

But as early as 1858 West had expressed the opinion that 
acute endometritis and metritis may develop in the train of 
blenorrhcea, and that the inflammation has a tendency to ex- 
tend through the tubes to the peritoneum. Dobson, Nelson, 
and Giles (1871) also speak of peritonitis as the extension of the 
blenorrhagic process through the tubes to the peritoneum, 
Mulreany (1871) of acute gonorrhoeal metritis which develops 
after menstruation cr abortion in women suffering from 
blenorrhcea. But Noeggerath (1872) was the first to lay due 
weight on the importance of the blenorrhagic process in 
diseases of the uterus and its appendages. As Noeggerath 
himself admitted at a later period (1887), he adopted the too 
pessimistic standpoint that almost every gonorrhoea in the 
male passes into a stage of latency, despite apparent re- 
covery, and that in this condition it may last for life and con- 
vey infection. This latent blenorrhcea in man was said to 
give rise to latent blenorrhcea in the female, manifested after 
a wnile by perimetritis and oophoritis. Ninety per cent, of 
women who marry men that have suffered from blenorrhcea 
are said to be attacked in this way. The majority of these 
women (49 out of 81) are sterile. After describing 50 cases 
which illustrate the different forms of latent gonorrhoea in 
women — viz., 1, acute perimetritis; 2, recurrent perimetritis; 
3, chronic perimetritis; 4, oophoritis — Noeggerath comes to 
the following conclusions : 

1. In man as well as in woman gonorrhoea persists de- 
spite its apparent cure. 

2. There is a latent gonorrhoea in men and women. 

3. Latent gonorrhoea in either sex may produce in a previ- 
ously healthy individual of the opposite sex an infection which 
may run its course in an acute or latent manner. 

4. Latent gonorrhoea in the female is manifested by peri- 
metritis (acute, chronic, recurrent), oophoritis, or catarrh of a, 
circumscribed part of the genital mucous membrane. 

5. The wives of men who have previously suffered from 
gonorrhoea are usually sterile, or they bear only one child, at 
the most three or four children. 

At first Noeggerath's conclusions encountered only opposi- 
tion. Williams (1876) described cases of blenorrhagic endo- 
metritis and oophoritis. Fritsch (1876) stated that blenor- 
rhagic vulvo -vaginitis was a local, easily curable disease. 



Blenorrhoea of the Sexual Organs. 273 

Sckroeder (1879) acknowledged that chronic inflammatory 
conditions of the female genitalia (vaginitis, endometritis, 
metritis, and perimetritis) are often caused by gonorrhceal 
infection, but he characterized Xoeggeratlrs opinions as ex- 
travagant. 

It was not until the discovery of the gonococcus that this 
question was cleared up and Xoeggeratlrs opinions were found 
to be in the main correct. 

The investigations which followed the discovery of the 
gonococcus threw light upon a number of obscure points. 

I. The Frequency of Gonorrhoea ix the Female.— 
Noeggerath believed that 80 per cent, of all married women 
suffered from latent gonorrhoea, but Oppenheimer (1884), who 
examined 108 pregnant women in Kehrer's clinic in Heidel- 
berg, found gonococci in 30 (27.7 per cent.). Among 32 puer- 
peral women Lomer (1885) found gonococci in 9 (28 per cent.). 
Schwarz (1886) examined 617 women; in 112 there was a 
strong suspicion of gonorrhoea, and this was confirmed in 77 
cases (12.4 per cent.) by the finding of gonococci. Saenger 
(1889) found among 1,930 women gonorrhceal infection in 230 
(12 per cent.), and he believes that one-eighth of all women 
who consult a gynecologist suffer from gonorrhceal infection. 

II. The site of blexorrhcea ix the female has also 
been explained by the gonococci investigations. 

In 1846 Hardy reported a case of primary uterine blenor- 
rhoea in a girl who, after coitus with a man suffering from clap, 
was attacked first by a purulent discharge from the uterus and 
only after a lapse of several days by a blenorrhoea of the vagina. 
Decourtieux (1880) called attention to the frequency of blenor- 
rhagic urethritis, and Ducos (1880) discussed blenorrhagic me- 
tritis, salpingitis, and peritonitis. Boutin (1883) gave an ex- 
cellent description of the clinical signs of localized chronic 
blenorrhoea in the female, and called attention to the fact that 
it may be localized, either in passing into the chronic stage or 
primarily, upon certain sites of predilection (follicles of the 
vulva, peri-urethral glands, Bartholin's glands, urethra, cervi- 
cal canal). Nevertheless, it was the prevailing belief that 
vaginitis and vulvitis with complicating Bartholinitis were 
the principal forms of blenorrhagic disease. 

Bumm (1884) was the first that regarded the cervical canal 
and not the vagina as the most frequent site of blenorrhoea. 
18 



274 Blenorrhcea of the Sexual Organs. 

Steinschneider (1887) stated that the urethra was affected 
in all recent cases. In 47 per cent, of all cases he found 
gonococci in the cervical canal, in 50 per cent, in the uterus. 
They may be found here after they have disappeared from the 
urethra. In the vulva and vagina the gonococci do not 
multiply or they are soon expelled by other cocci. 

Among 38 female gonorrhoeas which contained gonococci, 
Fabry (1888) found them 16 times in the urethra and cervix, 
20 times in the urethra, and twice in the cervix alone. Wel- 
lander (1889) found the gonococcus in the urethra in 89 per cent, 
of the cases, in the cervical canal in only 43.7 per cent. Di 
Bella and Ingria, Aubert, Eraud, Horand, and Pescione also 
regard the urethra as the favorite site of the gonococcus. 
Bruenschke (1891) gives the following frequency of localiza- 
tion: in the urethra 90 per cent., in the cervix 37.5 per cent., 
in Bartholin's glands 12.5 per cent. Luczny (1891) collected 
47 cases in Olshausen's clinic. Among these the gonorrhoea 
was located in the urethra in 40, the vulva in 12, Bartholin's 
glands in 17, the vagina in 19 cases. 

Finally, I have reported 2 cases in which chronic gonorrhoea 
in the female was located exclusively in the urethra, the other 
external and internal genitalia being entirely intact. 

III. The gravity of blenorrhagic disease in the 
female, its significance to the individual and to procreation. 

It has been learned that as a«rule the disease is not con- 
fined to the vulva, vagina, and urethra, but that it extends to 
the uterus, tubes, ovaries, and peritoneum. In fact, we now 
speak merely of acute and chronic gonorrhoea, because its ex- 
tension over the greater part of the sexual organs is regarded 
as a matter of course. 

1. The acute form develops from the conveyance of abun- 
dant purulent secretion, i.e., from infection by a man suffering 
from acute blenorrhcea. It generally begins with the symp- 
toms of acute vulvo-vaginitis and urethritis, a profuse puru- 
lent secretion which is apt to produce intertrigo, tenesmus, and 
burning during micturition. The clinical history may be com- 
plicated by acute suppurative Bartholinitis. The mucous 
membrane of the vulva, vagina, and urethra is intensely red- 
dened and covered with abundant creamy pus. On exten- 
sion to the uterus (acute metritis) fever develops, with violent 
pains in the pelvis and small of the back, enlargement and 



Blenorrhcea of the Sexual Organs. 275 

tenderness of the uterus, sanguinopurulent to purulent 
secretion from the uterine cavity. Extensive exudations in 
the pelvis and around the tubes and ovaries are the result of 
circumscribed peri-parametritis and perisalpingitis, and the in- 
flammation of the tubes may lead to foudroyant fatal peri- 
tonitis or to pyosalpinx. 

2. The chronic form is due to infection by an old, latent, 
not thoroughly cured gonorrhaea. It is most frequent in newly 
married women whose husbands enter matrimony while suf- 
fering from chronic gonorrhoea. The majority of the husbands 
regard themselves as cured, but we may again call attention 
to the fact that the absence of a " good-morning drop " does 
not exclude blenorrhcea. The morning urine should always be 
examined and the absence of clap shreds demonstrated. 

In typical cases the chronic form runs the following course : 
A young and previously healthy woman begins to complain 
soon after marriage. At first she notices merely an increased 
secretion from the genitalia, especially near the menstrual 
period. She is apt to suffer from burning and itching in the 
external genitalia. After a while a dull pain is felt in the pel- 
vis and small of the back, increasing after exercise. Just be- 
fore the menses the pains may become colicky. Pregnane}^ 
terminates either in abortion or it runs a normal course, but 
is followed, during the puerperal state, by perimetritis, peri- 
oophoritis, or circumscribed peritonitis. After delivery the 
symptoms increase in severity. Forced movements, running, 
dancing, even coitus become painful. Prior to the menses 
severe symptoms appear in the shape of colic which confines 
the patient to bed. The menstrual type is changed. It be- 
comes irregular, sometimes profuse, sometimes scanty. The 
general nutrition suffers. The patient emaciates, loses cheer- 
fulness and desire to work; finally typical hysteria develops 
with its manifold nervous symptoms. 

Examination of such women shows increased secretion from 
the genitalia. The vulva is pale, even unusually drj 7 ; at the 
opening of the excretory duct of Bartholin's gland a redness, 
like the tail of a comet, is visible. 

Pressure upon Bartholin's gland expresses a vitreous or 
milky secretion. A similar redness also appears upon one or 
the other peri-urethral (Skene's) follicle, or in a groove be- 
tween the caruncula and labia minora. A few condylomata are 



276 Blenorrhcea of the Sexual Organs. 

perhaps found at the border of the labia minora, the posterior 
commissure, or around the anus. 

The vagina does not exhibit pronounced morbid changes, 
perhaps merely redness and erosions of the posterior part. 
The portio vaginalis is somewhat enlarged and fluffy. In- 
creased secretion, which is usually purulent but may not pre- 
sent a morbid appearance, flows from the cervical canal. On 
palpation the uterus is found somewhat enlarged and tender 
on pressure; if there have been perimetral and parametral in- 
flammations, it is displaced and fixed in the abnormal posi- 
tion. The ovaries are enlarged, displaced and tender on pres- 
sure, and the broad ligaments are shortened and more rigid. 

IV. The diagnosis of blenorrhagic disease is not very 
difficult in acute forms. It depends upon the profusely secret- 
ing inflammation of the vulva, urethra, and vagina, but par- 
ticularly upon the demonstration of the gonococci. The diag- 
nosis of the chronic form is more difficult. The absence of 
gonococci in these cases does not exclude gonorrhoea. Hence 
Saenger (1889) lays emphasis upon the clinical standpoint and 
mentions the following clinical criteria: 

1. Demonstration of acute or chronic gonorrhoea in the 
male. 

2. If this is wanting, a reliable historj T of previous gonor- 
rhoea in the male. 

3. Ophthalmo-blenorrhcea in one or more of the offspring. 

4. Co-existing or previous purulent catarrhs, when other 
causes may be excluded. 

5. Disease of Bartholin's glands and redness along the ex- 
cretor3 T duct. 

6. Condylomata. 

7. Purulent or muco-purulent discharge from the cervix, 
in the absence of erosions or pseudo-erosions of the os uteri. 

8. Disease of the uterine appendages of the pelvic perito- 
neum. 

V. The question next arises whether the entire nosological 
picture just depicted is due to the gonococcus. 

In opposition to the view maintained by Bumm (1887) and 
Saenger (1889), that a part of the disease, especially that of 
the internal genitalia, the tubes, parametria, and ovaries, is 
due to mixed infection, Wertheim (1892) has demonstrated that 
the entire symptomatologj', even of chronic gonorrhoea, is due 



Blenorrhoea of the Sexual Organs. 27 7 

to the gonococcus alone. The demonstration of gonococci in 
the pus and tissue of diseased tubes and ovarian abscesses, the 
experiment of producing circumscribed peritonitides by pure 
gonococcus cultures, and particularly the culture of gonococci 
from tubal and ovarian pus with inoculation of the male ure- 
thra and production of typical gonorrhoea, constitute positive 
proofs. A few cases have been reported in which, in pyosalpinx 
and peritonitis, pus cocci were found in addition to gonococci, 
or the former alone were present. In these cases, however, 
we have to deal probably with secondary infections in which 
the gonococci were finally overcome. 

There appears to be no doubt that the gonococcus, when 
placed in the vagina or upon the cervix, spreads to the uterus, 
the tubes, and through the walls of the latter to the perito- 
neum and ovaries, and that it alone produces the entire dismal 
symptomatology of gonorrhoea in the female. 

I. URETHRITIS. 

General Remarks. 

The statements concerning the frequency of this disease 
differ in a very striking manner. Swediaur states that he 
never observed a case of urethritis in the female. Ricord says 
that in contagious blenorrhoea of the female the urethra is 
often affected alone, or at least participates in the disease of 
the other mucous membranes. The recent writers agree 
almost unanimously concerning the frequency of blenorrhagic 
urethritis, and that it is never absent in cases of recent infec- 
tion. Zeissl alone maintains that there are only 5 cases of 
urethral blenorrhoea among 100 cases of blenorrhagic vagini- 
tis. This striking difference of opinion is owing to the rapid 
and mild course of the acute stage, and to the readiness wi-th 
which chronic urethritis in the female is overlooked. Cheron 
states that in the female there is one acute urethritis to five 
chronic urethritides. 

Symptomatology. 

Thanks to the short and straight course of the female 
urethra, its simple structure, the absence of large glands, 
female urethritis is a milder affection than in the male. 

After a period of incubation, which Martineau estimates at 



2yS BlenorrJicea of the Sexual Organs, 

two to five days, the urethritis begins, in acute cases and in 
sensitive women, with slight chilliness, which appears only on 
one or two evenings, and slight malaise. At the same time 
the patients complain of mild burning and tickling on micturi- 
tion ; in some cases this is quite annoying for several days. 
These are the only perceptible symptoms, but not infrequently 
subjective symptoms are entirely absent, or there is slight 
burning- during micturition which is ignored or overlooked. 

On examination of the patient, who should not have urinated 
for several hours, the orifice of the urethra will be found swollen 
and reddened, the urethral mucous membrane intensely red- 
dened and perhaps somewhat prolapsed. On passing the 
finger into the vagina the urethra is felt as a firm cord which 
is tender on pressure. On pressing from behind forwards along- 
its course often quite large drops of creamy pus escape from 
the orifice. On microscopical examination this shows the 
same elements as in man, especially numerous gonococci in 
the pus cells. 

If the patient urinates into two vessels, we will find cloudy 
urine in the first, clear urine in the second vessel. Cloudiness 
of the second urine indicates coincident cystitis. There is no 
division of the urethra into two parts as in man. The female 
bladder possesses a true sphincter, which consists of smooth 
and striped muscular fibres, and forms a sharp boundary be- 
tween the urethra and bladder. There is no neck of the blad- 
der in the female, in the sense of a part which belongs at times 
to the urethra, at times to the bladder. However fall the 
female bladder — and, as is well known, its capacity is greater 
than in the male — all the urine remains in the organ, the 
urethra always forms a short canal, which is open anteriorly, 
firmly closed towards the bladder, so that regurgitation of 
pus from the urethra into the bladder is impossible. 

The few subjective symptoms which constitute the acute 
stage have usually disappeared in three weeks, at the furthest, 
and the patients, and indeed many physicians, then regard the 
blenorrhoea as cured. 

But this is not true. Female urethritis passes into a chronic 
stage much more often than has been hitherto believed. This, 
while not so serious, so far as our imperfect knowledge goes, 
as chronic blenorrhoea in the male, nevertheless presents suffi- 
cient danger. In the first place it may exacerbate after external 



Blenorrhcea of the Sexual Organs. 279 

irritants, as in the male. The patient not alone suffers from a 
contagious disease, or, at least, one which of£en becomes so 
at each relapse, but it may extend beyond its original bounda- 
ries and give rise to the symptoms of temporary urethro- 
cystitis, which is similar to that in the male, buts runs a milder 
and more rapid course. 

The symptoms of chronic urethritis in the female are exclu- 
sively objective. They are found on careful examination of 
the urethra after the patient has not urinated for several 
hours. Pressure on the urethra, from behind forwards, usually 
forces out a drop of thin, milky muco-pus. If the patient is 
allowed to urinate, after the vulva has been caref ulry cleansed 
of mucus, we find either sligiit cloudiness of the urine or clap 
shreds, as in the male. 

The female urethra is rich in follicles, which are situated 
along* the entire mucous membrane as well as at the orifice. 
These follicles may take part in the blenorrhagic process. 
They become swollen and sensitive and form small nodules, 
which disappear or enlarge and open into the urethra without 
being- attended by further consequences. 

There are two varieties of follicles which especially merit 
our attention. Both are situated in the vicinity of the exter- 
nal orifice. 

One form is situated in the lower wall of the urethra, to the 
right and left of the median line, and their two excretory ducts 
empty just at or within the external orifice. Skene (1880), 
Lormant (1883), Hamonic (1883), Boehm (1883), and Van Cott 
(1887) have made a thorougii study of blenorrhagic inflam- 
mation of these glands and the termination in suppuration 
with the development of urethro-vestibular and urethrovagi- 
nal fistulas. 

The second variety of these follicles is peri-urethral in the 
broader sense of the word. The} 7 number four or five, and 
usually surround the meatus, alongside of which they often 
empty with peculiar pocket-shaped dilatations. If one or both 
varieties of follicles are attended by Menorrhagia, careless ex- 
amination may lead us to diagnose blenorrhcea of the urethra 
itself. 

In examining a woman with blenorrhcea, pressure on the 
orifice extrudes pus, which is supposed to come from the ure- 
thra. But if the patient is allowed to urinate previously, i.e., 



28o Blenorrhoea of the Sexual Organs. 

if the urethra is cleansed, and the parts are carefully inspected 
during- the examination, we convince ourselves that the pus 
appears in the fissures at the side of the urethra. If the fol- 
licles had been previously squeezed and the pus removed, and 
if the urethra is then examined from behind forward, or if the 
patient is allowed to urinate, we can also demonstrate the pres- 
ence of chronic urethritis. 

Blenorrhagic inflammation of the follicles at the orifice is 
either chronic, i.e., a small quantity of pus is secreted without 
any symptoms, or it is acute and relapsing". One or another 
of the follicles enlarges, the meatus becomes unsymmetrical, 
the mucous membrane over the follicle is reddened. A small 
point of pus soon appears, an abscess forms in the follicle, 
rapidly opens and discharges, and closes with equal rapidity. 
In a short time this process is repeated in the same or another 
follicle, and this may continue for a long time. Slight pain on 
palpation is the only symptom of this affection, which is usually 
unnoticed by the patient. Guerin called it external urethritis, 
and proved its blenorrhagic character and contagiousness by 
some accurate observations. Small, insignificant fistulas may 
result from the rupture of the abscess into the urethra and 
vulva at the same time. 

Pathological Anatomy. 

The anatomy of the disease has been little studied. In a 
patient who died of typhoid fever, Mercier describes the mucous 
membrane of the blenorrhagic urethra as uniformly red in the 
lower part, the remainder was injected in patches. 

In a servant w T ho died of cysto-pyelitis and nephritis, Mur- 
chinson found both kidneys in a condition of acute nephritis, 
the renal pelves and ureters filled with pus, the bladder dis- 
tended with purulent urine, its mucous membrane, like that 
of the urethra and vagina, intensely reddened. 

Examination with the endoscope in the acute stage usually 
shows uniform redness, swelling, and velvety loosening of the 
mucous membrane. In chronic cases the mucous membrane 
is reddened in patches and stripes, or the redness, associated 
with slight erosion, merely surrounds the openings of a few, 
usually prominent, follicles. I never found granulations, but 
the number of cases which I had the opportunity to examine 
was small. 



Blenorrlicea of the Sexual Organs. 281 

Diagnosis and Prognosis. 

The diagnosis is evident from the symptoms just described. 
Attention must be paid particularly to the origin of the pus, 
whether it comes from the urethra or the follicles of the mea- 
tus. In chronic urethritis frequent examination is necessary, 
especially after the patient has not urinated for some hours. 
In otherwise negative cases, a decision is arrived at from ex- 
amination of the urine after its retention for several hours and 
after careful cleansing of the vulva. This is always annoy- 
ing, and often impracticable for external reasons. 

The prognosis of urethritis in the female is always more 
favorable than the corresponding affection in the male. 
Chronic urethritis is much more amenable to treatment, the 
conditions for recovery are more favorable. Unfortunately 
the latter affection often escapes our observation and treat- 
ment. 

Treatment. 

In the acute stage the treatment is hygienic and sympto- 
matic. The regimen, as regards exercise, food and drink, is 
the same as in the male. 

If the subjective symptoms have disappeared but suppura- 
tion persists, balsams internally, and local injections of hyper- 
manganate of potash and sulphate of zinc, are indicated. The 
injections are made, when the bladder is moderately full, with 
the ordinary clap syringe half filled. The bladder should 
always contain urine in order to prevent direct action of the 
injection fluid upon the wall of the bladder, provided it enters 
the bladder, which is more apt to occur on account of its ana- 
tomical structure. 

The torpidity of female urethritis soon permits active local 
treatment, particularly the application of tincture of iodine or 
a solution of nitrate of silver (2 to 5 per cent.) through a short 
endoscope or by means of little tampon brushes (smooth nar- 
row strips of wood covered with cotton). 

Folliculitis of the urethral meatus is an obstinate affection, 
which is only cured by destruction of the follicles. This is 
done with a narrow stick of lunar caustic, or, better still, with 
the fine point of a Paquelin cautery. 



282 Blenorrhcea of the Sexual Organs. 

II. VAGINITIS. 

General Remarks. 

Vaginitis occupies the most peculiar position among* the 
more common blenorrhagic affections. Originally regarded as 
the most frequent form and the prototype of female sexual blen- 
orrhcea, its blenorrhagic character is now denied by many. 
Bumm endeavored to show by a series of careful investiga- 
tions that a proliferation of gonococci in the vagina and their 
entrance into its epithelium does not take place. He claimed 
that the site of blenorrhcea in these cases is the cervical canal 
or uterine cavity, and the pus produced in these parts, and 
which contains gonococci in abundance, flows into the vagina. 
Here it irritates and macerates the vagina and causes inflam- 
mation of its surface, just as blenorrhagic secretion entering- 
the preputial sac produces balanitis, which is not regarded as 
blenorrhcea. The pus from the cervix mingles with the secre- 
tion of the vagina and therefore contains gonococci, but the 
vaginitis itself is catarrhal, i.e., it results from simple irrita- 
tion and is not a blenorrhagic affection. 

Bumm attempted to prove this view in various ways. In 
the first place he claims that, according to his microscopical 
examinations, gonococci only enter cylindrical epithelium, that 
they cannot pass through pavement epithelium, and whenever 
cylindrical and pavement epithelium come in contact, the 
gonococci disappear where the latter begins. The vagina is 
covered with firm pavement epithelium, which resists the en- 
trance of gonococci. We have already stated that this view 
is disproved by recent investigations. 

Bumm also examined portions of the inflamed mucous 
membrane of the vagina, and never discovered gonococci 
therein. 

Finally, he kept blenorrhagic secretion in direct contact 
with the vaginal mucous membrane for twelve hours and 
could never produce vaginitis in this way. The vagina also 
remains normal, despite the most severe, cocci-containing cer- 
vical or uterine blenorrhcea, which permits the abundant se- 
cretion to flow into the vagina, provided the irritant action of 
this secretion is prevented by securing its thorough removal. 
On the other hand, the delicate epithelial lining of the youth- 



Blenorrhcea of the Sexual Organs. 283 

ful vagina was not absolutely proof against the invasion of 
gonococci, but the symptoms ran a much more mild and rapid 
course. 

That there is a vaginitis which is associated with blenor- 
rhcea of the urethra and of the cervix and uterus, cannot be 
denied. But according to these views of Bumm and the more 
recent investigations of Steinschneider, the cervical or uterine 
blennorrhoea is produced by the primary infection, and the 
secretion stagnates in the vaginal canal and produces vagini- 
tis. In accordance with this notion, cervical or uterine blenor- 
rhcea must be present in every case of vaginitis, a point con- 
cerning which our present statistics are silent, but which 
Schwarz, as the result of his examinations, denies. That vag- 
initis may communicate blenorrhcea would be explained by 
the fact that, together with the secretion of the cervical canal, 
it also contains its gonococci, which proliferate in the vaginal 
secretion as in an incubator, and may even cover the vagi- 
nal epithelium, but do not penetrate it. In addition to the 
gonococci a considerable number of other cocci and bacteria 
also find favorable conditions for proliferation in the vaginal 
secretion. 

These views are opposed by Schwarz in every detail. He 
states that in many recent cases vaginitis may be demon- 
strated although the uterus is entirely intact, that the obsti- 
nacy of the vaginitis proves its specific character, and that the 
presence of gonococci in the deepest layers of epithelium can 
be proven by scraping the vaginal walls with a curette, after 
previous irrigation of the vagina. 

Saenger (1889) also states that the vagina remains free from 
gonorrheal disease when its epithelium is firm and contains 
many layers, but that true gonorrheal vaginitis does occur, 
even in adults, in young people, in pregnancy, in many women 
with delicate skin and blond hair, and when the entire mucous 
membrane is succulent. This opinion is confirmed by Tou- 
lon's investigations. 

I am also convinced from my own experience that acute 
vaginitis may develop without disease of the cervical canal. 

Symptomatology. 

Like other blenorrhagic affections in the female, vaginitis 
possesses the peculiarity of running quite rapidly through the 



284 Blenorrhcea of the Sexual Organs. 

acute stage, soon passing- into a chronic stage, and of present- 
ing relatively few symptoms during the acute period. 

The following are the symptoms of acute vaginitis : In the 
beginning the patients experience a feeling of weight, dragging 
and burning in the genitalia, and there is increased secretion, 
at first mucous, then purulent, which stiffens the clothing, and 
has a yellowish color. The pains increase and radiate towards 
the pelvis and thighs; they increase on movement and defeca- 
tion, and not infrequently compel sensitive women to take to 
bed. Slight chilliness and a feeling of dullness and fatigue are 
added, the secretion increases, and, by its irritation, causes 
more or less marked vulvitis, and also gives rise to intertrigo 
and eczema by floAving into the inguinal folds and upon the 
perineum and thighs. 

In addition to the urethritis and vulvitis which are usually 
present, examination shows swelling of the introitus vaginas. 
The fimbria and caruncles are swollen, their mucous mem- 
brane reddened and eroded; the swollen follicles are shown by 
punctate, dark, often elevated and intensely reddened spots. 
A considerable amount of creamy pus, which is neither viscid 
nor gelatinous, wells up out of the introitus, especially on press- 
ure upon the perineum. On passing the finger into the vagina 
considerable elevation of temperature is felt, and the mucous 
membrane is also felt to be more rigid, its folds more promi- 
nent. In many cases the entrance of the well-oiled finger is 
impossible, the pain produced thereby so violent that spasm 
of the sphincter vaginae (vaginismus) sets in. 

As a matter of course examination with the speculum is 
impossible in these cases. In others this can be done, and the 
following changes are noticed after the pus has been wiped 
off : In places the epithelium seems to be lost, and superficial, 
easily-bleeding erosions are formed. In some cases, usually 
not the most acute ones, the markedly infiltrated folds appear 
to be covered by deep red granules, which are quite uniform 
and may attain the size of a hemp seed. The entire vagina 
then appears granular, a condition known as psorelytrie, vagi- 
nitis granulosa or papillaris. This form is especially frequent 
in gravid females. Martineau states that he found it particu- 
larly in scrofulous and cachectic individuals. 

The mucous membrane of the portio vaginalis is also 
swollen, its follicles more prominent. Superficial erosions, 



Blenorrhoea of the Sexual Organs. 285 

perhaps as large as a pea, are also found, particularly on the 
lower lip. In many cases — whether it is true of all I am un- 
able to say — the orifice of the cervical canal is reddened, partly 
eroded, gaping-, and from it escapes a tough purulent plug. 

The course of the acute blenorrhoea is quite typical. The 
symptoms attain their height in eight to ten days and then 
slowly diminish, so that the vaginitis is usually cured in three 
to four weeks. But relapses are not rare. These occur in 
part after external noxious influences, but particularly after 
menstruation, which is always followed, even if the process is 
entirely healed, by a short stage of subacute vaginitis with 
increased secretion and redness of the mucous membrane. 

Chronic vaginitis, which is a sequel of acute vaginitis that 
is maintained by local irritation or by frequent relapses, is 
either diffused over the entire mucous membrane, or localized. 

In both cases subjective symptoms are absent; in the 
former the secretion is still considerable, in the latter it is not 
notably increased. In diffuse vaginitis examination with the 
speculum shows thickening of the mucous membrane, whose 
folds are very prominent and covered with granulations ; the 
color is partly red, partly even livid; erosions are found par- 
ticularly in the fornix and on the portio vaginalis. 

In the localized cases, one or more patches of reddened, 
partly eroded and swollen mucous membrane are seen in the 
deeper portions of the vagina, particularly in the posterior 
fornix. 

Chronic vaginitis terminates in a change which is found 
with special frequency in prostitutes. This is a form of fibrous 
degeneration known as xerosis vaginae. The mucous mem- 
brane becomes rigid and thick, it dries from destruction of the 
follicles, the epithelium is thick and white, like chronic stoma- 
titis with psoriasis mucosa?, and the condition is incurable. 

Diagnosis and Prognosis. 

The diagnosis may be made from the symptoms mentioned. 
The proof of its blenorrhagic character is obtained from the 
presence of co-existing blenorrhagic affections and the demon- 
stration of gonococci. 

With regard to the former, the urethra must first be ex- 
amined. Acute or chronic urethritis, the demonstration of 



286 Blenorrhcea of the Sexual Organs. 

suppuration, with or without inflammatory symptoms, from 
the urethra or the follicles around its orifice, and the discovery 
of gonococci, which is hardly ever attended with difficulty, are 
important diagnostic indications. 

The discovery of g-onococci in the vaginal secretion itself is 
more difficult. In the first place it contains a larg-e number 
of other micro-organisms which interfere with the recognition 
of the gonococci. Indeed, Lomer states that the vaginal se- 
cretion is unsuited to the demonstration of gonococci. Bumm 
also attaches little importance to examination of the vaginal 
secretion, in which, according- to his belief, gonococci occur 
only secondarily. Schwarz, on the other hand, maintains the 
existence of a primary vaginal blenorrhcea, and discovered 
g-onococci in the vaginal mucous membrane, after irrigating- 
the canal freely and removing- the secretion and micro-organ- 
isms. After the irritating irrigation a reaction develops in 
the vaginal mucous membrane in the shape of active cell pro- 
liferation, which brings the gonococci, intra-cellular and free, 
to the surface. If some secretion is now scraped with the 
knife or curette from the mucous membrane, we can, as a rule, 
discover the g-onococci. 

The prognosis must be made with great caution. Vagini- 
tis itself is often cured with great difficulty, and especial con- 
sideration must be paid to the fact that an extension of the 
process to the uterus may give rise to the most serious, even 
incurable complications, which may seriously endanger not 
only health but even life. 

Treatment. 

Acute vaginitis not infrequently runs its course spontane- 
ously, if cleanliness and removal of the secretion are attended 
to. The subacute and chronic forms are much more obstinate. 
Hence the treatment of acute vaginitis is expectant and 
mildly astring-ent, that of chronic vaginitis is strongly astrin- 
gent, even caustic. 

In the first and most severe stage of acute vaginitis treat- 
ment is usually impossible on account of the violent pains 
which characterize the affection. It is then our object to se- 
cure a rapid termination of the acute stag-e, by rest in bed, 
regulation of the bowels, cool sitz-baths, cold compresses on 
the genitalia and perineum, mild and unirritating diet. Potas- 



Blenorrhcea of the Sexual Organs. 287 

sium bromide, chloral hydrate and morphine relieve the nerv- 
ous excitement which is so frequent at this period. 

When the acute symptoms have subsided so that instru- 
ments may be introduced into the vagina,, we resort to local 
treatment, consisting in the application of astringents and the 
removal of the accumulated secretion. 

Treatment which is carried out under the control of the 
eye is always the most effective. It is therefore best to intro- 
duce a speculum, carefully cleanse the vaginal mucous mem- 
brane with tampon brushes and then to apply the astringent 
to the vagina by means of these brushes or by irrigation. 
We prefer 1 to 2 per cent, solutions of permanganate of potash. 
Applications of a 1 per cent, solution of nitrate of silver may 
be used, in addition, every two or three days, if the symptoms 
are subacute, especially in vaginitis granulosa. After each 
cauterization or irrigation the vagina is filled with cotton 
tampons, which are fastened to one another with thread and 
introduced through the speculum. 

This method of treatment, which is entirely in the hands of 
the physician or a midwife, is usually impracticable, except in 
a hospital service. And so the treatment must often be car- 
ried out by the patient. In such cases it is best to use an irri- 
gator, to the rubber tube of which is attached a vaginal tip, 
a slightly curved hollow bulb, whose tip is perforated like a 
sieve. For irrigation we order 1 per cent, solutions of per- 
manganate of potash, chlorate of potash, sulphate of zinc, or 
a 2 per cent, solution of alum, the vagina being irrigated three 
times a day with about 2 quarts of the slightly warmed solution. 
The part which first enters the vagina coagulates the secre- 
tion and removes it in shreds, the remaining fluid comes in 
direct contact with the vaginal walls. Tamponing of the va- 
gina must usually be abandoned in these cases, as the tam- 
pons recommended are not suitable. The physician should 
examine with the speculum every three or four days, and may 
then make applications of 1 per cent, solution of nitrate of 
silver, tincture of iodine or liquor ferri sesquichlorati. These 
remedies, applied every third day, are to be recommended 
particularly in subacute cases. 

In obstinate subacute vaginitis the astringents mentioned 
should be applied daily for several successive days. The va- 
gina is brushed and tamponed. On the following day the 



288 BlenorrJioea of the Sexual Organs. 

tampon is removed, the mucous membrane cleaned and again 
brushed. If this is repeated for several days, the mucous 
membrane begins to exfoliate in shreds. The brushings are 
then discontinued, but the above-mentioned irrigations are 
employed daily until the mucous membrane is regenerated; if 
it has not regained the normal appearance, the procedure is 
again begun. Alum, which is dusted on tampons or sewed up 
in bags of mull, acts very vigorously in this way. A mixture 
of powdered sulphate of copper and alum (10 : 100) acts in the 
same way. Other astringents, such as sulphate of zinc, sul- 
phate of copper, alum in gelatine capsules, are introduced into 
the vagina in a similar manner. 

Corrosive sublimate has been largely used in recent times. 
Schwarz (1887) recommended the following procedure: The 
vulva and vagina are first cleansed and washed with a .1 
per cent, solution; then the vagina is carefully scrubbed, 
through a speculum, with plugs of cotton dipped in a 1 per 
cent, solution; then a tampon of iodoform gauze is introduced. 
This is repeated in three days; at the end of three days more 
the tampon is removed, and the patient now continues irri- 
gations with gV per cent, solution twice a day for two weeks. 

Saenger also gives the preference to corrosive sublimate. 
In order to prepare the way for the better entrance of the 
sublimate, he begins with the introduction of a tannin-glycer- 
in tampon. On the following day the vagina is cleansed by 
irrigation with soap and water, then corrosive sublimate 
(1 : 500-1000) is introduced through a Ferguson speculum and 
soaked up with cotton until it remains clear. Then a tampon of 
iodoform-glycerin is inserted. In obstinate cases the parts 
are also brushed with tincture of iodine. Foveau (1889) 
first brushes with biniodide of mercury (1 : 4000) and then ap- 
plies an iodoform-glycerin tampon. Brennan (1889) irrigates 
the vagina, then applies a 2-4 per cent, solution of chloride 
of zinc, then a tampon of equal parts of boracic acid and gly- 
cerin. 

Great care must be devoted to disease of the portio vagi- 
nalis and cervical canal. Erosions of the portio vaginalis are 
to be touched up ; in suppuration from the cervical canal and 
uterus, the parts are brushed with astringents or injections 
made with Braun's syringe. Hypertrophy of the portio vagi- 
nalis with development of granulations requires vigorous cau- 
terization, even partial excision, i.e., surgical interference. 



Blenorrhcea of the Sexual Organs. 289 

In chronic cases attention must always be paid to the gen- 
eral constitution. The nutritive disturbances, constipation 
and anaemia, which are so frequent in women, must be relieved 
by suitable remedies. 

Menstruation indicates complete rest until a few days after 
its cessation, and vigorous cauterization is especially contra- 
indicated. 

Acute vaginal blenorrhoea may also be the subject of treat- 
ment during pregnancy, but, as a matter of course, with the 
utmost caution. The cure of chronic blenorrhoea under such 
conditions is a labor of Sisyphus, which it is best to put off 
until parturition is completed. 
19 



CHAPTEE VI. 

COMPLICATIONS OF BLENORRHCEA IN THE 
FEMALE. 

I. VULVITIS. 
General Remarks. 

Among diseases of the sexual organs in the female, vulvitis 
occupies a position analogous to that of balanitis in the male. 

Diseases of the vulva may occur independently as the re- 
sult of various local irritants, and are then non-infectious, 
purely local affections, superficial inflammations. Correspond- 
ing to the hybrid anatomical position of the vulva between in- 
tegument and mucous membrane, tbey also hold pathologi- 
cally a position midway between catarrh and acute eczema. 

Similar forms occur as part-symptoms of acute urethral 
and vaginal blenorrhoeas. It has not been decided whether 
these vulvitides, which are so common as attendants of acute 
sexual blenorrhoea, are real blenorrhagic affections, or merely 
the result of irritation by the blenorrhagic secretion. The 
entirely analogous balanitis is certainly the effect of irritation 
by the secretion. 

In children, on the other hand, there is a true, primary, 
blenorrhagic vulvitis, which is caused by the transmission of 
blenorrhagic, gonococci-containing secretion, and by the local 
increase of the cocci upon the vulva; it remains localized or 
extends to the vagina. Apart from Fraenkel's cases, which 
are not entirely clear, Aubert, Widmark, Cseri, Lenander and 
Israel have reported instances in which the presence of gono- 
cocci and usually the infection were demonstrated. 

Symptomatology. 

Although vulvitis usually heals rapidly and easily, it often 
produces very alarming symptoms. Whether it occurs alone 
or as a complication, it always gives rise to itching and burning 



Blenorrhcea of the Sexual Organs. 291 

which soon increase to pain. The passage of urine over the 
inflamed surfaces is especially painful; movement, particu- 
larly walking", is also painful or even impossible. The second 
striking symptom is the abundant secretion of creamy, foul- 
smelling pus. 

On examination in the most acute cases, the inner surface 
of the thighs, often almost to the knee, and the inter-crural 
folds, are reddened, partly eroded and weeping. The labia 
majora are swollen, reddened and hot. Their surface, espe- 
cially at the edge, and the hairs of the pubis, are sticky, and 
covered with crusts of pus. The labia minora are often so 
cedematous that they protrude beyond the labia majora. 
Their surface likewise, together with the inter-labial folds, is 
reddened, swollen, partly eroded. The lining of the vestibule 
is intensely swollen, of a deep red color, loosened, often vel- 
vety, even finely granular. Deeper red patches or punctate, 
slightly elevated spots, which belong to the swollen follicles, 
are seen not infrequently. The vicinity of the excretory ducts 
of Bartholin's glands is also characterized by more intense 
redness. The entire diseased surface is covered with a more 
or less thick layer of pus, containing numerous micro-organ- 
isms, also gonococci if the disease is blenorrhagic. Their 
diagnosis, however, is often rendered very difficult by the mul- 
titude of other cocci and bacteria. 

In addition to the acute purulent vulvitis just described, 
we also find milder, subacute, muco-purulent vulvitides, char- 
acterized by slight intensity of the subjective and objective 
symptoms. 

Vulvitis usually terminates in recovery. It rarely be- 
comes chronic, and only after gross neglect. The secretion 
then remains increased, slight itching and pricking become 
permanent, the lining membrane of the vulva becomes slightly 
thickened, of a slate gray to violet color. 

Chronic vulvitis is more often localized. The process dis- 
appears from the surface, and retires to a number of glands, 
among others to the glands of Bartholin, which will be dis- 
cussed separately. But the other vestibular glands may also 
take part in the affection — for example, the glands around the 
orifice of the urethra, the numerous glands and follicles on 
the inner surface of the labia minora, which are partly scat- 
tered, partly arranged in groups. In these localized, extremely 



292 BlenorrJicea of the Sexual Organs. 

insidious forms, which are usually entirely devoid of symp- 
toms, the vulva appears to he normal, pale red in color, and 
the secretion is not increased. It is only on careful examina- 
tion that we find, at one or more of the places mentioned, one 
or a few dark red patches, often not larger than a lentil, whose 
mucous membrane is fluffy or velvety, even granular; perhaps 
a few swollen follicles, which can be better seen than felt, are 
situated underneath. A little secretion, mucus or muco-pus, 
can be squeezed from the excretory ducts of Bartholin's and 
the peri-urethral glands, and Schwarz states that small pain- 
ful ulcers may develop from the suppuration of such follicles. 

Diagnosis. 

The diagnosis is made without difficulty from the symptoms 
mentioned. It is more difficult to distinguish the blenorrhagic 
from the non-blenorrhagic forms. It must be kept in mind 
that blenorrhagic vulvitis occurs only in children as an inde- 
pendent affection, but that it usually extends in such cases to 
the vagina. The demonstration of gonococci is usually not 
difficult in these cases. In adults vulvitis is rarely an inde- 
pendent affection, but is a link in the chain of an extensive 
blenorrhagic process, which usually involves the urethra, va- 
gina and cervix. These parts should therefore be examined in 
vulvitis. The existence of vulvitis, while the urethra, vagina, 
and uterus are healthy, speaks against its blenorrhagic char- 
acter. We must then examine for all those factors which are 
usually followed by symptomatic vulvitis, such as soft chan- 
cre, primary and secondary syphilitic lesions; finally, we must 
take into consideration those conditions which favor the de- 
velopment of idiopathic vulvitis, such as masturbation, un- 
cleanliness and accumulation of sebum, pregnancy. 

Treatment. 

The treatment of acute vulvitis is quite simple. Washing 
with lukewarm baths and irrigations, insertion of cotton be- 
tween the labia, into the vestibule and the inter-labial folds, 
in order to prevent contact of the inflamed parts, and absorp- 
tion of the secretion, often prove sufficient. In more obstinate 
cases the application of astringents materially aids recovery. 



Blenorrhoea of the Sexual Organs. 293 

So long- as the inflammatory symptoms are violent, we may 
use plumbum aceticum basicum solution ( 3 iiss : § vj.), into 
which pledgets of cotton are clipped and inserted into the parts. 
When the acute symptoms have subsided we may apply, in 
the same way, other astringents, such as tannin, sulphate of 
zinc, and alum in -J to 1 per cent, solutions. In these cases the 
most effective agent is nitrate of silver in \ to 5 per cent, so- 
lution, brushed upon the inflamed parts, which are then cov- 
ered with dry cotton. 

Schwarz (1886) soaks cotton tampons in .1 per cent, solu- 
tion of corrosive sublimate and applies the Labarraque dress- 
ing", i.e., calomel affcer the previous application of a 5 per 
cent, solution of sodium chloride. 

As a matter of course other blenorrhagic affections which 
may be present, must be treated in a suitable manner. 

Chronic vulvitis is much more obstinate, and vigorous 
local treatment is indicated. The patches of infiltrated, 
swollen, perhaps suppurating glands can usually be cured 
only by the application of caustics. Brushing with concen- 
trated solutions of nitrate of silver (1 :10 to 5), with the solid 
stick or chloride of iron effect material benefit, but I have al- 
ways found that the best plan is the use of the Paquelin cau- 
tery, whose finest tip, brought to a white heat, is carried 
gently into the larger follicles or is applied several times to 
reddened patches. 

II. INFLAMMATION OF BARTHOLIN'S GLANDS. 
General Remarks. 

Inflammation of Bartholin's glands, extending from the 
vulva, is a frequent complication of blenorrhagic infection in 
the female. The question whether every Bartholinitis is 
blenorrhagic in origin is not yet decided. 

Bonnet (1889) regards 9 cases out of 10 acute Bartholini- 
tides as blenorrhagic, and chronic Bartholinitis as usually 
specific. Feleki and Pollaczek (1889) distinguish 4 varieties of 
the disease : 1, a simple, and 2, a blenorrhagic catarrh of the 
excretory duct, 3, a simple, and 4, a blenorrhagic suppurating 
Bartholinitis. Saenger (1889) maintains that non-blenorrhagic 
disease of Bartholin's glands is at least extremely rare, and 
he regards the chronic cyst-producing affection as uniformly 
gonorrhoea!. 



294 Blenorrhoea of the Sexual Organs. 

In 1883 Arning had demonstrated the pressnce of gonococci 
in the pus of acute and chronic Bartholinitis. Bumm, Saenger, 
and Gersheim assume a mixed infection, particularly for the 
suppurative forms, and they found pyogenic organisms, 
streptococci, in addition to the g-onococci. In a case of acute 
Bartholinitis, Toulon (1893) found g-onococci upon the epithe- 
lium of the excretory duct which had been converted into pave- 
ment epithelium, but not within the gland itself. 

a.— ACUTE BARTHOLINITIS. 

Symptomatology. 

Acute Bartholinitis either develops directly as a complica- 
tion of acute blenorrhoea or from an exacerbation of the in- 
flammation in chronic Bartholinitis, even during long-standing 
chronic blenorrhoea. 

It runs its course as a very acute inflammation with a ten- 
dency to suppuration. Whether as the result of acute recent 
or chronic inveterate blenorrhoea, it generally follows some 
exciting cause, such as neglect, forced coitus in prostitutes, 
excessive exercise. A swelling develops within a few hours in 
one of the labia majora, usually the left, accompanied by all 
the signs of acute inflammation, such as redness, elevation of 
temperature, intense pain. On examining the reddened, swollen 
labium majus (the labium minor of the corresponding side is 
usually implicated in the oedema) we feel, in the posterior third, 
a firm, tense, sharply defined nodular swelling, as large as a 
hazel nut, which can be felt distinctly beneath the integument 
of the labium. Pressure on this nodule discharges pus from 
the excretory duct of Bartholin's gland, though not in all 
cases. The inflammatory symptoms, the swelling and red- 
ness, increase for two or three days, and extend to the pras- 
putium clitoridis and to the inguinal region on the same side. 
The formerly sharply defined nodule loses its distinct contour 
and is lost in the general swelling; it becomes doughy, and 
finally (usually very soon) fluctuation is felt, which is first dis- 
tinct upon the inner surface. The beginning of suppuration is 
generally signalized by chilliness; the pains, hitherto violent 
only on contact, become throbbing, dragging, shooting, and 
are also very severe spontaneously. After gradual thinning 
of the skin, perforation takes place, usually upon the inner 
surface of the labium, more rarely in the fold between the la- 



Blenorrhcea of the Sexual Organs. 295 

bium majus and minor. In very rare cases the pus perforates 
the capsule of the gland, but not the integument, and perfora- 
tion may then occur into the perineum or even the rectum. 
Fistulas may develop if the perforation occurs in two places at 
the same time. The perforation opening is usually quite large, 
jagged, with gangrenous or thin livid edges; the destruction 
not infrequently extends farther after perforation. The dis- 
charged pus is bloody, foul smelling, not infrequently mixed 
with gangrenous shreds. These spontaneously rupturing ab- 
scesses and the accompanying gangrene often cause consider- 
able destruction of tissue, which exhibits a rapid tendency to 
recovery as soon as perforation takes place. 

The termination in induration is much rarer than that in 
suppuration. The inflammatory symptoms then subside be- 
fore suppuration has begun, and the gland remains as a firm 
nodule, which soon becomes painless. The termination in 
resolution rarely occurs, however early treatment is adopted, 
and never occurs when the disease runs its course spontane- 
ously. 

Treatment. 

The therapeutic indications are very simple. So long as 
there is no suppuration, vigorous antiphlogosis is indicated, 
rest and application of cold. 

As soon as suppuration is demonstrable, surgical interfer- 
ence must be adopted. The pus must be evacuated as rapidly 
as possible by long incisions, the abscess cavity closed by an- 
tiseptic treatment, introduction of iodoform, irrigation with 
solutions of corrosive sublimate. 

In the rare cases of induration poultices often produce ab- 
sorption. Otherwise this painless but usually annoying symp- 
tom is relieved bv excision and enucleation of the nodule. 



&.— CHRONIC BARTHOLINITIS. 

Chronic Bartholinitis occurs, although rarely, as a sequel 
of acute non-suppurative or partly suppurative inflammation. 
It occurs much more frequently as a complication of chronic 
blenorrhcea. In the former event the disease extends to the 
parenchyma of the gland, in the latter it is confined to the ex- 
cretorv duct. If the °iand is affected it is usuallv felt as a 



296 Blenorrhcea of the Sexual Organs. 

painless, firm nodule, pressure on which discharges muco-pus 
or a milky, even clear mucous fluid. This secretion, whatever 
its appearance, usually contains gonococci, i.e., it is contagious. 

In other and more frequent cases increased firmness of the 
gland cannot be felt. We then find the mucous membrane 
around the excretory duct reddened, perhaps slightly loosened. 
Secretion is not discharged spontaneously. But if pressure is 
exerted on the vicinity of the gland, a mucous, milky, gono- 
coccus-containing secretion escapes, either in drops or in a large 
amount. The larg-e amount of secretion is explained by the 
fact that cystoid dilatations form in the gland or its excretory 
duct, and that these contain the abundantty-produced morbid 
secretion until the walls of the cyst acquire sufficient tension 
or it is evacuated by pressure from without. If the patient is 
examined when the cysts are filled with secretion, the escape 
of muco-purulent fluid from the excretory duct very soon clears 
up the diagnosis. But if the cyst has just been emptied and 
no secretion appears, the redness around the excretory duct 
will, at the most, arouse suspicion. But we often cannot make 
a diagnosis of the affection, and hence of the fact that the 
woman is the bearer of an infectious blenorrhagic process, in- 
asmuch as examination of the other genitalia is followed by 
negative results. Indeed, chronic Bartholinitis, like the disease 
of the peri-urethral follicles, is often the sole localization of 
chronic blenorrhoea in the female. 

Both affections are important in this respect, particularly 
to the police surgeon, who must attend to the examination of 
prostitutes. If the inspection hour is known to the prostitutes, 
the latter, many of whom suffer from chronic localized blenor- 
rhoea, may squeeze out the cysts, either intentionally or unin- 
tentionally, while washing the genitalia, and thus often remove 
the only appearance which may prove the existence of blenor- 
rhcea and the infectiousness of the patient. 

Chronic Bartholinitis, like peri-urethral and cervical blen- 
orrhcea, explains some hitherto obscure points in the pathology 
of blenorrhoea. 

It explains the fact, frequently observed by competent 
authorities, that a woman, from whom a man has undoubtedly 
acquired blenorrhcea, may be examined and reg-arded as 
healthy, if the examination is made at a time when the secre- 
tion from the peri-urethral or Bartholin's glands is not visible. 



BlenorrJicea of tJie Sexual Organs. 297 

It also explains the fact that a woman may infect some, 
but not all, of several men with whom she has cohabited in 
rapid succession. Some found the secretion from the giand at 
the time of coitus, the non-infected ones did not. 

Le Pileur (1877) was the first to call attention to the infec- 
tiousness of this secretion, and the gonocoeci which have been 
found in it remove all doubt. 

The affection is extremely obstinate. It may exacerbate 
and lead to inflammation and suppuration under the influence 
of irritating- causes. Spontaneous recovery is hardly ever to 
be looked for. 

Treatment. 

In chronic cases the excretory duct is always dilated, so 
that it is possible, by means of an Anel syringe, to inject as- 
tringent and caustic fluids into the duct and its cysts. But I 
regard this method of treatment as unreliable and tiresome. 
It is always best to introduce a grooved director into the ex- 
cretory duct, to incise the latter and the cysts, and then to 
destroy them by cauterization. If the gland is indurated, it 
should be enucleated. 

III. INFLAMMATION OF THE UTERUS AND ITS APPEND- 
AGES. 

The uterus and its appendages, when attacked by blenor- 
rhcea, present various forms of disease, which are claimed by 
gynecology, and with which we will now concern ourselves 
very briefly. 

a. Acute Blenorrhagic Metritis. — This disease is always 
the result of an acute blenorrhagic infection, and develops as 
the continuation of the blenorrhagic process in the vagina and 
cervical canal. Other symptoms of acute infection, such as 
urethral, vulvo-vaginal blenorrhcea, are also always present. 
Hardy reports a case of primary acute uterine blenorrhcea in 
which, unlike the ordinary ascending course, the symptoms of 
vaginal and urethral blenorrhcea did not develop until the 
end of a few days. 

Acute uterine blenorrhcea, as the continuation of an acute 
infection, usually develops brusquely. Together with chill and 
fever, there appear rapidly increasing dull pains in the lower 
abdominal region and the small of the back. The patients, 



298 Blenorrhoea of the Sexual Organs. 

who create the impression of a serious illness, take refuge in 
bed on account of the exacerbations of the pain on movement. 
On examination of the genitalia we find, in addition to the 
previously mentioned signs of acute blenorrhoea, that the por- 
tio vaginalis is swollen and plump, its mucous membrane is 
reddened, perhaps eroded. Violent pain is produced by bring- 
ing the portio vaginalis into the speculum or touching it with 
a tampon. Muco-sanguinolent, then sanguino-purulent, finally 
purulent secretion flows in large amount from the cervical 
canal. On palpation the uterus appears to be enlarged and is 
very tender. After a few days the acute symptoms subside 
and the disease recovers or more often passes into the chronic 
stage. The inflammatory symptoms may also extend to the 
tubes, ovaries and peritoneum; in the severest cases they may 
give rise to acute purulent peritonitis with a fatal termina- 
tion. The extension of acute blenorrhoea to the uterine ap- 
pendages is shown in Mercier's case, in which the patient died 
of typhoid fever. The patient was a prostitute, art. nineteen 
years, who had been suffering from blenorrhoea for several 
weeks, acquired typhoid fever, and daring its course experi- 
enced intense pains in the pelvis. 

The autopsy showed : the inner surf aces of the labia majora 
and minora were swollen and reddened, excoriated here and 
there ; the labia minora covered with small granulations. The 
bladder contained a small amount of purulent urine ; its mucous 
membrane, especially at the orifice, was reddened, likewise the 
mucous membrane of the urethra and vagina ; the folds of the 
latter were deepened. In the posterior fornix were small gran- 
ular vegetations. The portio vaginalis was reddened, the broad 
transverse os and the cervical canal were bluish red in color. 
The cavity of the uterus had a dark color like the lees of wine. 
The Fallopian tubes presented signs of inflammation and con- 
tained muco-pus. The peritoneum was healthy, except around 
the fimbria and ovaries, where it was reddened and adherent 
to these organs. 

Peritoneal exudations into the pelvis, around the tubes and 
ovaries and in Douglas's cul-de-sac, are more frequent. These 
usually suppurate and perforate; absorption is rare. Ceppi 
(1887) found gonococci in a circumscribed peritoneal exudation 
which was opened through the vagina. 

b. Chronic Blenorrhagic Metritis. — This develops more 



Blenorrhoea of the Sexual Organs. 299 

rarely than the acute form, and usually as a direct chronic 
complication of chronic blenorrhoea. It is observed particu- 
larly in young- women whose husbands entered matrimony 
with a gonorrhoea which still contained gonococci. The cocci, 
whose virulence has been diminished by their long-protracted 
proliferation on the same soil, produce directly a chronic proc- 
ess. In many cases this is located in the vulva or its glands, 
but slight redness and the formation of granulations may also 
develop in the vagina. In other cases, however, the vulva 
and vagina appear to have been skipped and remain entirely 
normal, while the mucosa of the cervix and uterus is attacked 
at once. The morbid symptoms on the part of the vulva and 
vagina are mild and are attributed to the defloration, esx^e- 
cially if they occur soon afterwards, and consist of burning and 
itching in the genitalia with somewhat increased discharge. 
The symptoms proper do not set in until the uterus is affected. 
The patients then experience dull pain in the pelvis and small 
of the back, especially after bodily strain, excesses in coitus, 
before and during menstruation. Examination with the spec- 
ulum shows swelling, redness, slight e version of the cervical 
mucous membrane with a little muco-purulent secretion. 
Digital examination shows slight enlargement and tenderness 
of the uterus. 

Strains and excesses, menstruation, but particularly par- 
turition and child-bed, produce exacerbations. At the men- 
strual period the exacerbation begins a few days before the 
period as violent colicky pains, the period is usually delayed, 
the menstrual discharge very scanty, and the muco-purulent 
secretion very abundant for some days afterwards. The pre- 
mature occurrence of the menses and metrorrhagia are less 
frequent. These exacerbations may also further the extension 
of the process to the perimetrium, peritoneum, tubes and 
ovaries. 

The treatment of gonorrhoeal endometritis, which should 
always be intrusted to competent gynecologists, must be as 
radical as possible, in order to prevent the extension of blenor- 
rhoea to the tubes, etc. With the exception of the first and 
most violent stage of acute metritis, it is always local and 
consists of irrigations and instillations, done through a uterine 
catheter, either with or without previous dilatation of the cer- 
vical canal. Saenger (1889) recommends solutions of corro- 



300 Blenorrhcea of the Sexual Organs. 

sive sublimate, combined with 2 per cent, solutions of chloride 
of zinc, creolin, or creosote. Sinclair (1889) prefers tincture 
of iodine, which he applies for two or three days in succes- 
sion, then waits until the scurf is exfoliated, and begins the 
applications anew. 

Schwarz makes continuous irrigations of the uterine cavity 
with yf^ to yfo- per cent, solution of corrosive sublimate, or 
1 to 2 per cent, solution of carbolic acid. 

Perimetritis. — Noeggerath distinguishes three forms : 

1. Acute Perimetritis with or tvithout Parametritis. — 
The patients begin to complain soon after marriage ; they grow 
tired easily, the menses become profuse, finally acute, and vio- 
lent inflammation sets in. Or pregnancy sets in, during which 
the patients complain of vague pains in the abdomen, and it is 
nob until child-bed that an acute parametritis or perimetritis 
develops. Or, finally, the women are suddenly attacked, dur- 
ing complete health, by an acute, foudroyant, fatal para- 
metritis. 

2. Recurring Perimetritis. — This form is associated with 
purulent salpingitis. Purulent masses, which are retained in 
the tubes, escape under the influence of fear, excitement, coitus, 
introduction of the uterine sound, and give rise to circum- 
scribed perimetritis. The first attack is always acute, the ex- 
udation abundant and purulent. The subsequent attacks 
diminish in intensity and extent. At each seizure the patient 
experiences a violent pain, associated with nausea, which lasts 
a few days and is located between the second and third thirds 
of Poupart's ligament. The pain disappears in a few days, 
leaving behind shooting pains after meals, neuralgias in the 
hips and abdomen. 

3. Chronic Perimetritis. — This is manifested by latero- 
version of the uterus, whose fundus is usually turned toward 
the right; tenderness in Douglas's sac, in which firm bands 
can be felt. 

Salpingitis and Oophoritis. — Salpingitis is a frequent 
blenorrhagic affection— indeed, according to Saenger, it is the 
principal form of the disease. We have already mentioned its 
connection with recurring perimetritis. Tait and Howard 
reported cases of gonorrhoeal pyosalpinx. In Westermark's 
case a pyosalpinx was mistaken for extrauterine pregnancy 
and removed by laparotomy. The walls of the extirpated 



Blenorrhoea of the Sexual Organs. 301 

tube were infiltrated and thickened; in the purulent exuda- 
tion were found typical gonococci. Ortmann's case is espe- 
cially instructive. A woman, set. twenty-two years, had been 
married for a year to a man whose history showed several 
attacks of clap. Eight weeks after the first confinement 
she was taken sick, and complained particularly of burn- 
ing* during micturition and violent pains in the abdomen. 
Examination showed enlargement of the left ovary, right 
oophoritis and salpingitis. Laparatomy and extirpation of 
both ovaries and tubes revealed : purulent salpingitis, hema- 
toma ovarii, peri-salpingitis, and peri-oophoritis, on the right 
side. Catarrhal salpingitis, peri-salpingitis, peri-oophoritis, 
on the left side. Both tubes very sinuous and dilated, their 
contents purulent. A circumscribed abscess in the right tube. 
The right ovary as large as a plum and contains a cyst filled 
with blood, in addition to dropsical follicles. The pus in the 
right tube contains numerous gonococci which could be stained 
in a typical manner. The epithelium of the tubal mucous 
membrane is wanting; its folds have coalesced into high ridges, 
so that the deeper portions seem to be converted into cavities 
which are filled with blood and pus. The mucous membrane 
is thickened, markedly infiltrated, in a condition of purulent 
destruction in places, the muscular bundles are thinned, the 
intra-muscular connective tissue thickened. 

Finally, Wenheim demonstrated the presence of gonococci 
in three cases, not alone in the tubal contents, but also in the 
tissue of the tubes. According to Saenger, salpingitis occurs 
as the direct extension of gonorrhoea from the uterus under 
the form of a pyosalpinx, with or without thickening of the 
walls; escape of pus from the tubes (due to external causes) 
gives rise to circumscribed pelvic peritonitis; oophoritis de- 
velops almost exclusively from peri-oophoritis, which in turn 
gives rise to secondary chronic oophoritis, with disorders of 
circulation and ovulation, development of cysts, etc. 






OHAPTEE TIL 

COMPLICATIONS OF BLENOKRHCEA IN BOTH 

SEXES. 

I. GONORRHCEAL RHEUMATISM. 

General Remarks. 

Gonorrhceal rheumatism is one of the complications which 
attracted the attention of physicians at a very early period. 
Petrus Forestus (1507), Musgrave (1703) and Baglivi mention 
it as a proof of the syphilitic character of gonorrhoea. Swe- 
diaur describes it in detail. Hunter, Selle, Cooper, Brodie, 
Eisenmann, Baumes and Carmichael report cases and discuss 
its connection with clap. Eagle (1836) attributes it to the un- 
timely use of copaiba and to improper treatment of gonor- 
rhoea. But it is not until the appearance of Brandes's article 
(1854) that the history of gonorrhceal rheumatism realty be- 
gins, and since then it has become generally known and 
studied, and the subject of numerous monographs, theses and 
discussions. 

Etiology. 

From the time that the clinical side of gonorrhceal rheu- 
matism was discussed, the specific character of the symptoms, 
its course and connection with clap were determined, another 
question was broached, viz., its origin and mode of connection 
with gonorrhoea. This question was the subject of many dis- 
cussions, and gave rise to several theories that bore the mark 
of the study rather than of the anatomical laboratory. 

The first writers who connected blenorrhcea and rheuma- 
tism, regarded the latter as a direct blenorrhagic disease, plac- 
ing it in the same rank with epididymitis and prostatitis. But 



Blenorrhoea of the Sexual Organs. 303 

the observation that joint swellings may develop after other 
irritations of the urethral mucous membrane, especially after 
catheterization, soon led to the view that blenorrhoea acted 
merely as an irritant of the urethral mucous membrane, which 
provoked the rheumatism. But this irritation produced by 
blenorrhoea was supposed to possess a specific quality because, 
as Fournier emphasized, it is only the blenorrhagic and not 
the other forms (catarrhal) of inflammation of the urethra 
which produce rheumatism. Zeissl also gave in his adherence 
to this view. 

Other writers, however, particularly Thiry and Guyon, 
adopted the opposing- stand-point. They recognize no gen- 
etic connection between blenorrhoea and rheumatism, and be- 
lieve that the blenorrhoea, as a depressing agent, merely 
favors the development of diatheses which have hitherto been 
latent in the individual. 

To Guerin, Lorain and Lasegue the fact that blenorrhoea 
could produce remote localizations was a proof that it was a 
general disease. They believe that gonorrhoea has a long 
period of incubation and that no remote complications will 
ensue if we can master the disease while it still remains local, 
but that complications occur if the clap lasts beyond the stage 
of incubation. Martineau also favors this theory. 

There is also a vaso-motor theory of the development of 
gonorrhceal rheumatism. This regards the disease as a vaso- 
motor disturbance, which is produced by reflex, vaso-motor ir- 
ritants starting from the inflamed urethra. Lewin was the 
chief advocate of this theory. 

The discovery of the gonococcus formed a landmark in this 
question. But it also taught that so-called gonorrhceal rheuma- 
tism is not, etiologically, a single disease. Thus in a series of 
cases which are characterized clinically by a mild course, the 
gonococcus has been demonstrated in the joints. Such cases are 
undoubtedly blenorrhagic, metastatic, due to the conveyance 
of the gonococci through the blood into the joints. It is an 
interesting fact that blenorrhagic vulvo-vaginitis and ophthal- 
mia neonatorum may also give rise to arthritides in which 
gonococci have been found. 

In a second group of cases which ran a more severe course, 
pus cocci have been found in the joints, and we evidently have 
to deal with a pysemic process dependent on the blenorrhagia. 



304 Blenorrhcea of the Sexual Organs. 

Finally, Guyon and Janet (1889) found micro-organisms in 
the pus of three arthritides, and, like Fuerbringer (1890), re- 
gard such cases as the result of ptomaine poisoning. 

Symptomatology. 

Among 2423 cases of blenorrhoea Grisolle observed gonor- 
rhoea! rheumatism 68 times (2.8 per cent.), and Besnier and 
Jullien also give a proportion of 2 per cent. 

It is more frequent in men than in women, though the lat- 
ter do not escape entirely. Age exerts no influence. It only 
complicates true blenorrhagic affections and is never observed 
in pseudo-blenorrhagic diseases, such as balanitis. But the 
old belief that it only complicates urethral blenorrhoea is er- 
roneous. Recent cases have been reported in which the joint 
affection occurred in blenorrhcea of the vulva, vagina and con- 
junctiva. Lucas describes two cases of blenorrhcea conjunc- 
tivae in infants who suffered from swelling of several joints 
after birth; the course of the disease led Lucas to make a 
diagnosis of gonorrhceal rheumatism. Hartley reports cases 
of vulvo-vaginitis in girls of three, four, five, seven and eight 
years who were attacked by swelling of the joints. In four 
cases gonococcci were found in the secretion of the vulvo- 
vaginitis. 

There are no accurate statistics with regard to the period 
at which the disease begins. But observation and the study 
of numerous reports of cases seem to show with tolerable cer- 
tainty that it is not the recent but the older cases of blenor- 
rhoea that are complicated with rheumatism. Roustan states 
that it does not develop before the third week after infection. 
Struppi makes the interesting statement that in his eight cases 
of gonorrhoeal rheumatism the affection always followed dis- 
ease of the pars posterior, which was also complicated by 
prostatitis in three cases. Loeb also regards gonorrhoeal 
rheumatism as a complication of posterior urethritis. 

Gonorrhceal rheumatism usually attacks several joints, 
more rarely it is confined to one joint. Among 348 cases col- 
lected by Jullien, 205 were poly-articular, 143 were mono-ar- 
ticular. 

The following statistics, collected from numerous writers, 
give the site of the disease: 



Blenorrhcea of the Sexual Organs. 



305 



Knee joint, 
Tibio-tarsal joint, 
Wrist joint, . 
Finger joints, 
Elbow joint, . 
Shoulder joint, 
Hip joint, 
Maxillary joint, 
Metatarsus, . 
Sacro-iliac synchondrosis, 
Sterno-clavicular joint, 
Chondrocostal joint, 
Intervertebral joint, 
Peroneo-tibial joint, 
Crico-arytenoid joint, . 



136 times. 


59 


a 


43 


« 


35 


i( 


25 


a 


24 


a 


18 


ce 


14 


a 


7 


a 


4 


a 


4 


a 


2 


<( 


9 


a 


1 time. 


2 times 



376 



Many attempts have been and still are made to construct 
for gonorrhceal rheumatism a special symptomatology which 
will always permit it to be distinguished from other diseases 
of the joints, but such attempts are fruitless. Although the 
disease possesses certain typical characteristics, it runs its 
course under various symptoms. We may furnish the follow- 
ing schema of the different varieties : 



r 



1. Articular 
Rheumatism 



mono-articular 



{ 



j acute (arthritis). 

( chronic (hydrarthros). 

i acute. 

•< subacute. 

f chronic. 



I polyarticular 

1 

2. Peri-articular (nodose) rheumatism. 

3. Synovitis tendinum. 

All these forms receive their characteristic impress as blen- 
orrhagic diseases less from the clinical history than from the 
following circumstances: 1. They occur during a blenorrhagic 
urethritis and follow its course, acute exacerbations of the 
former being followed by exacerbation of the rheumatic com- 
plication, remission of the former by remission of the compli- 
cation, and recovery of both occurring at the same time. 2. 
On fresh infection there is a decided tendency to recurrence of 
the complication. 3. These forms, although they begin acutely, 
present less acute symptoms than true rheumatism, and 
20 



306 Blenorrhcea of the Sexual Organs. 

always exhibit a tendency to pass rapidly into a subacute and 
chronic stage. 

Arthritis Blenorrhagica. — This is the most frequent va- 
riety and is regarded as a prototype of blenorrhagic dis- 
ease of the joints. It begins acutely or is preceded by a 
prodromal stage, consisting of malaise and tenderness in 
several joints. This is followed by very rapid onset of the 
arthritis. A rapidly increasing swelling develops in one of 
the large joints, usually the knee. The pain may be very 
violent or moderate, the exudation and tension usually very 
considerable, fluctuation always distinct. On account of the 
marked distention the joint is usually fixed in a semi-flexed 
position. The general symptoms accompanying this swelling 
are very acute in the first few days. Fever develops (with noc- 
turnal exacerbations to 39.5° C. and morning remissions to 37.5° 
even to 36.8°) and continues for several days. But the symp- 
toms of acute inflammation do not last long, although the ex- 
udation and the consequent swelling do not diminish. The 
pain and fever disappear, and merely a feeling of tension, due 
to the exudation, remains, so that the use of the joint is only 
hindered by the exudation. In the most favorable cases this 
subacute condition may disappear, by absorption of the infil- 
tration, in a few weeks. But so long as any infiltration re- 
mains, an injury, especially one that causes an exacerbation of 
the urethritis, may produce an acute exacerbation of the proc- 
ess, with renewed fever and painful swelling. This exacer- 
bation also disappears rapidly, but its frequent recurrence 
very strongly predisposes the process, which already exhibits 
a tendency to a chronic course, to pass into hydrarthros. 

A rarely observed termination is that in suppuration. This 
is indicated by chills and violent fever daring the acute stage. 
The swelling of the joint increases, its coverings, hitherto pale, 
become reddened, the pain increases in violence and becomes 
throbbing, pulsating. The capsule of the joint ruptures, the 
pus makes its way outwards between the sheaths of the mus- 
cles and tendons. If recovery does occur, ankylosis results, 
but this variety generally terminates fatally by pyaemia. 

Voelker (1868), Hamonic (1887), and Martel (1887) men- 
tion, as a rare complication of acute articular rheumatism, 
phlebitis of the saphenous, femoral, and iliac veins. This 
usually ends in recover, but may also end in obliteration or 
even in fatal embolism. 



Blcnorrhooa of the Sexual Organs. 307 

Hydrarthros. — The chronic inflammation develops either 
directly or as a sequel of arthritis after frequent relapses. In 
the former event there is a gradually increasing' exudation 
and therefore swelling of the joint, without subjective symp- 
toms. The patient usualty discovers it accidentally. On ex- 
amination of the joint, which is entirely free from pain on 
pressure and passive movement, distinct fluctuation is felt, as 
the result of the accumulation of fluid. If this is marked, 
extreme flexion and extension are prevented, but otherwise 
the functions of the joint are intact. In extreme grades the 
joint ligaments seem to be loosened. 

This results in an often very striking abnormal mobility 
of the joint, which impairs the use of the limb. The hydrar- 
thros is capable of extremely rapid absorption and may disap- 
pear spontaneously in a few days, while in other cases it resists 
treatment for months. When the disease lasts a long time 
plastic changes usually occur in the joint. Some of the exu- 
dation is absorbed, but crepitation and creaking set in, and 
deformities develop which interfere partly or entirely with the 
functions of the joint. 

Acute Polyarticular Blenorrhagic Rheumatism. — This 
variety possesses the greatest resemblance to acute articu- 
lar rheumatism, develops rapidly as a painful, often consid- 
erable swelling of several joints, attended by a non-continued 
fever. But there are always certain differences between 
it and acute articular rheumatism. The number of joints 
affected is never as large as in the latter disease. There are 
usually only two (symmetrical) joints attacked, very rarely 
more than three or four. The fever is not as high as in genu- 
ine rheumatism. In the latter several joints are attacked at 
the same time, the blenorrhagic form usually consists of seve- 
ral attacks of monoarticular rheumatism, recurring at short 
intervals. The simultaneous acute affection of two or more 
joints is rare. The tendency to relapse after morbific influ- 
ences which act upon the blenorrhcea, is also peculiar to this 
form. A further characteristic is shown by treatment. It 
does not react to quinine and salicylate of soda as promptly 
as genuine rheumatism. 

Subacute Polyarticular Blenorrhagic Rheumatism. — 
Next to arthritis this is the most frequent variety; it is 
analogous to the form just described, except that the fever 



308 Blenorrhcea of the Sexual Organs, 

never exceeds 38.5°; the subjective symptoms are slight or 
moderate, often in striking- contrast to the considerable swell- 
ing. 

Polyarticular Chronic Rheumatism, which develops di- 
rectly or as the termination of the acute and subacute forms, 
is distinguished from hydrarthros merely by its localization 
in several joints. 

Periarticular Blenorrhagic Rheumatism. — In both sexes 
this begins with a prodromal stage of malaise and drag- 
ging pains in the limbs. Suddenly a joint becomes swollen, 
but the exudation is not situated in the cavity of the joint. 
There is, on the other hand, marked infiltration of the peri- 
articular tissue and firm oedema of the integument. The 
joint then appears to be thickened and deformed in a manner 
similar to that observed in gout. The pains are moderate, the 
fever is quite high at first, but soon disappears. The mobility 
of the joint is usually unaffected, indeed abnormal mobility 
may result. The affection generally recovers, but ankylosis 
is also observed. 

Blenorrhagic Tendo-vaginitis. — This rare disease, which 
was investigated chiefly by Maymou, develops at all periods, 
but usually in older blenorrhoea, after the third week of 
its existence. It begins with chilliness and slight fever, fol- 
lowed by pains — one to several hours in duration — which 
appear and disappear in this or that joint or tendon. Finally 
the pain becomes fixed in the sheath of a tendon, which 
becomes the site of a douglry, painful swelling that simu- 
lates fluctuation; it often extends quite a distance along 
the tendon. At the same time the hitherto pale skin as- 
sumes a rosy to dark-red color, and finally becomes the seat 
of an often painful oedema. In the beginning of the acute 
stage the pain is violent and spontaneous, and is increased on 
pressure and movement. Later the spontaneous pains dimin- 
ish, but the pain on movement often remains long after the 
swelling has disappeared. The disease attacks either a system 
of tendons which possess communicating sheaths, or separate 
tendons. The extensor digitorum communis, flexor pollicis, 
dorsal flexors of the toes, are the ones attacked most fre- 
quently. The acute stage, which lasts a few days, is followed 
by remission of the inflammatory symptom, but a period of 
several weeks always elapses before the exudation is entirely 



Blenorrhcea of the Sexual Organs. 309 

absorbed. Fresh infection or relapse of the blenorrhoea is 
followed by relapse or renewed disease of the sheath. The 
synovitis is very often combined with the various forms of 
arthritis. 

A series of nervous, "spinal" symptoms follow gonor- 
rhoeal rheumatism in rare cases and occasionally follow the 
gonorrhoea directly. Gutherz (1852) described a case of ob- 
stinate neuralgia of the internal pudendal nerve in a patient 
suffering from gonorrhoea, and which recovered at the same 
time as the latter. Fournier (1868) observed obstinate 
sciatica, which returned with every fresh infection, in men 
who suffered from gonorrhoea, with or without synovitis. 
Coutagne reports two cases of blenorrhagic arthritis with 
crural and inguino-scrotal neuralgia. Gaillard reports two 
cases of double sciatica with gonorrhceal epididymitis. Urdy 
(1878) calls attention to the fact that gonorrhceal rheumatism 
is apt to be complicated by muscular atrophy, especially of 
extensors of the large joints. This observation has been con- 
firmed by many other writers. Numerous writers have ob- 
served in addition a series of other symptoms, such as cincture 
pain, paresthesias of the legs, increased cutaneous sensibility 
and reflex excitability, spinal tenderness and muscular spasms, 
so that they speak of a concomitant " spinal affection " in their 
cases. 

Pathological Anatomy. 

Although the number of autopsies in gonorrhceal rheuma- 
tism is not very small, we do not? obtain from them a picture 
of the common benign forms, because the fatal cases are malig'- 
nant but rare forms, which run an acute progressive course. 

Fournier reports an autopsy on a case of acute suppurative 
blenorrhagic arthritis of the elbow. The joint was filled with 
pus, the articular cartilages eroded and entirely separated 
from the ulna, which was laid bare. Haslund describes four 
cases of purulent blenorrhagic arthritis, in one of which, that 
necessitated amputation, the knee joint contained ichorous 
pus, the cartilage was destroyed, the ends of the bones eroded, 
the periosteum separated by suppuration high up on the femur. 

In a case of suppurative blenorrhagic rheumatism in a sol- 
dier, set. twenty-five years, who died of pyaemia, Wyszrmirski 
found pus in both elbow joints and the left shoulder joint, and 



310 Blenorrhcea of the Sexual Organs. 

demonstrated gone-cocci in the pus. Pollard presented, "before 
the London Pathological Society, specimens from a woman of 
nineteen years, who had suffered for thirty-six days from va- 
ginal blenorrhcea. She suffered from fever, pain in the knee 
and stiffness of the right hip, and died of embolism of the pul- 
monary artery. The autopsy showed embolism of the left 
common iliac vein, the internal iliac and vaginal veins. The 
knee and hip joints contained pus, the articular cartilages 
were eroded. 

Punctures and incisions furnish us with information con- 
cerning the nature of the exudation in cases which run a fav- 
orable course. Volkmann punctured a knee joint which was 
the seat of gonorrhceal rheumatism and removed four ounces 
of a mucous, greenish, slight cloudy fluid, which deposited, after 
standing, a sediment consisting of pus cells. The majority of 
the cells presented fatty degeneration ; no epithelial cells were 
found. Laboulbene punctured the knee joint in two cases and 
evacuated a deep yellow fluid, consisting of sticky, alkaline, 
purulent, cloudy serum ; it contained pus corpuscles and fibrin, 
but no mucin. In one case Haslund removed about three 
ounces of sero-purulent fluid. 

The punctures were also decisive as regards the question 
of the presence of gonococci. Petrone (1883) was the first 
to demonstrate them in the fluid of blenorrhagic arthritis. 
Kammerer also found numerous gonococci in one of two exam- 
ined cases. Horteloup found them in a blenorrhagic sterno- 
clavicular joint. In the fluid aspirated from an inflamed knee 
joint Hall found large epitheloidal cells and a few pus cells, 
with gonococci in both as well as free in the exudation. Smir- 
noff detected groups of gonococci in the pus cells of a sero- 
purulent gonitis. We have already mentioned Hartley's 
positive cases. A few negative observations, on the other 
hand, have also been reported. 

Deutschmann (1890) has recently made a positive demon- 
stration of gonococci in gonorrhceal arthritis. Lindemann 
(1892) and Stein (1892) have also obtained positive results by 
pure cultures. 

The findings of gonococci are thus contrasted with the 
fatal cases of Haslund, Wyzemirski, and Pollard, which 
create the impression of pyaemic disease. We are therefore 
justified in the opinion that gonorrhceal rheumatism some- 



Blenorrhcea of the Sexual Organs. 311 

times develops as a true blenorrhagic affection, sometimes as 
a mixed infection, a pysemic complication. 

In regard to other rheumatic affections, we only have 
Pollosson's (1888) findings in a case of blenorrhagic synovitis. 
He found a muco-purulent fluid in the sheath of the tendon, 
and fungous granulations upon the parietal wall of the sheath 
and in longitudinal strips upon the tendon itself. Unfortu- 
nately no examination forgonococci was made. 

Diagnosis and Prognosis. 

The diagnosis of gonorrhoeal rheumatism is evident from 
the symptoms. One of the most important diagnostic factors 
is the well-established fact that gonorrhoeal rheumatism 
always exhibits a tendency, after it has appeared as a compli- 
cation of clap, to return after fresh infection. The diagnosis is 
therefore undoubted if we learn from the patient that he also 
suffered from rheumatic symptoms during one or more previ- 
ous claps. 

The diagnosis is more difficult in a first attack of urethritis, 
or in a later infection in which rheumatic symptoms appeared 
for the first time. The possibility of the simple coincidence of 
clap and an independent genuine rheumatism cannot be laid 
aside. But even here there are certain data which furnish 
guides to the correct diagnosis. These include : 1. The small 
number of joints involved. Gonorrhoeal rheumatism, often, 
monoarticular, is rarely as polyarticular as genuine rheuma- 
tism, and seldom attacks more than two or three joints. Even, 
in polyarticular blenorrhagic rheumatism the disease rarely 
attacks two or more joints at the same time with the same 
acuteness. 2. Diminished intensity and duration of the acute 
symptoms as compared with genuine rheumatism. The fever 
and pain are not as marked as in genuine rheumatism, and 
disappear more rapidly, so that there is soon a disproportion 
between the persistent objective signs of joint disease and the 
rapidly developing apyrexia and absence of pain. 3. The oc- 
currence of exacerbations of the rheumatism coincidently with 
exacerbations of the blenorrhoea. 4. Treatment. The action 
of quinine, salicylic acid and antipyrin, which is so prompt in 
true rheumatism, is very slight in the gonorrhoeal form. 

The prognosis should be guarded. Apart from the possi- 
bility of the occurrence of pyarthros, with all its grave conse- 



3 r 2 Blenorrhoea of the Sexual Organs. 

quences, complete recovery is often not effected even in the 
mild cases ; the transition into hydrarthros may not be prevent- 
able, and thus the persistence of chronic disturbances (which 
are usually slight at first but are apt to be aggravated later 
on) must be regarded as a possible contingency. 



Treatment. 

The treatment hitherto has been a thankless task. Specif- 
ics are unknown, and we are therefore confined to symptomatic 
measures. Regulation of the hygiene and diet may prevent 
those influences which might cause an exacerbation of the 
blenorrhcea and therefore of the rheumatism. Heroic treat- 
ment of the gonorrhoea is to be employed with caution, because 
this is usually followed by temporary exacerbations of the 
urethritis, and these may influence the course of the joint dis- 
ease. 

In the recent acute stage we use antiphlogistics, but when 
the acute symptoms have disappeared and in the chronic cases 
we recommend absorbents, tincture of iodine, warm compresses, 
massage, sulphur baths, iodine preparations internally. 

Taylor (1887) recommends oil of gaultheria, 10 to 20 drops, 
in capsules three to four times a daj 7 . 

Rubinstein (1890) recommends potassium iodide, gr. xlv.-lx. 
daily; Rifat (1880) phenacetin, gr. xlv. a day, gradually in- 
creasing to 3 ij. ; Morel-Lavalee (1891) iodide of mercury, 
gr. iss. daily. 

II. BLENORRHAGIC ENDOCARDITIS. 

The knowledge that gonorrhoea may be complicated by 
cardiac affections dates back only to the middle of this century. 
Although blenorrhagic rheumatism was known earlier, many 
authors, for example, Trousseau, expounded the doctrine that it 
is never complicated by heart disease and is thus distinguished 
from genuine acute articular rheumatism. Brandes (1854) was 
the first to report two cases of blenorrhagic rheumatism — one 
his own case, the other reported by Lehmann — which were 
complicated, the first by endocarditis, the second by pericardi- 
tis. Hervieux and Sigmund also observed, the former endo- 
carditis, the latter pericarditis, as complications of blenorrhagic 



BlenorrJioea of the Sexual Organs. 313 

rheumatism. Desnos (1877) discusses blenorrhagic endocarditis 
and reported a fatal case with autopsy. Morel (1878) collected 
thirteen cases. Pfuhl mentions a case of blenorrhoea which 
was complicated by cystitis, conjunctivitis, polyarticular rheu- 
matism, endocarditis and pericarditis, and recovered. Baudin 
reported a case of endocarditis without rheumatism. Up to 
date forty cases have been reported in literature. 

Blenorrhagic endocarditis is, as we see, a rare disease which 
occurs in part as a complication of a rheumatism accompany- 
ing blenorrhoea, in part, but more rarely, as a direct complica- 
tion of the blenorrhoea. Among the thirteen cases collected 
by Morel, in eleven the rheumatism and heart disease both 
appeared as complications, and only in two cases did the car- 
diac affection alone complicate the blenorrhoea. There is a 
striking predominance of the male sex. Sigmund is the only 
one who has observed the cardiac affection in women. 

Concerning the etiology of the endocarditis we have been 
entirely in the dark, but Weichselbaum's case is calculated to 
shed some light on the question. In a patient who had an 
acute enlargement of the spleen, a gonorrhoea of three weeks' 
standing with mucous secretion containing gonococci, and 
who died of endocarditis, the middle aortic leaflet presented a 
deep loss of substance with abundant soft, grayish-white or 
grayish-red vegetations; the loss of substance extended to the 
adjacent aortic leaflet, to the mitral valve and through the wall 
of the aorta to the tricuspid valve; the free border of the left 
aortic leaflet was thickened. Streptococcus pyogenes was 
found by the microscope and by cultures in the vegetations on 
the valves. Hence endocarditis, like several other complica- 
tions, must be regarded as the result of a mixed infection, and 
the gonorrhoea as an exciting cause which favors the invasion 
of the pus coccus. 

Ely's case is analogous in many respects to that of Weich- 
selbaum. The patient died after cerebral symptoms, which 
had terminated in left hemiplegia. The autopsy showed, in 
addition to blenorrhagic urethritis, congestion of the brain, 
old pericardial adhesions, recent vegetations of the mitral 
valve, enlargement of the spleen, which contained numerous 
small infarctions, and embolic foci in the kidneys. The mitral 
vegetations and the splenic and renal infarctions contained 
numerous pus cocci (staphylococcus and streptococcus). His 



314 Blenorrhcea of the Sexual Organs. 

(1892), on the other hand, claims to have demonstrated the 
gonococcus in the ulcerations of ulcerative endocarditis in a 
patient who died with septicemic symptoms. 

It is evident, then, that endocarditis may develop as the 
sole complication of a blenorrhcea, and in rarer cases it may 
occur as part of a pyaemia following- gonorrhoea. In the 
latter event it is always the result of a mixed infection. 
Whether the former is always the result of mixed infection is 
still doubtful. 

In Leyden's case (1881) the pericarditis and endocarditis 
were also a part of pyaemia. The patient, who suffered from 
urethral gonorrhoea, was first attacked by epididj^mitis, then 
by arthritis of several joints, chills, high fever, loss of strength; 
he died of pulmonary oedema. The autopsy showed peri- 
carditis, endocarditis of the aortic valve, splenic enlargement 
and infarctions, enlargement of the liver and kidne3 r s. 

The symptomatology differs in no respect from that of 
genuine endocarditis or of those forms which accompany true 
articular rheumatism. 

The inception is either brusque, with high fever, chills and 
the general symptoms of serious illness, or it is gradual and 
accompanied by moderate elevation of temperature and gastric 
S3 T mptoms. In the former event the fever reaches 40° or even 
41° C. The patient is then attacked by a feeling of oppression 
and dyspnoea, the heart's action is violent and irregular, and 
may present auscultatory signs even at this time. At the end 
of a few days a remission occurs ; this may continue or it may 
soon be replaced by an exacerbation. Embolism may lead to a 
rapid fatal termination during the first or a subsequent exac- 
erbation. Or the affection passes from a remission into a 
chronic stage, and a valvular lesion with its consequences de- 
velops. The mitral valve is attacked more frequently than 
the aortic. The endocarditis may be complicated with peri- 
carditis, the latter very rarely develops alone. In the acute 
stage the disease may extend from the endocardium or peri- 
cardium to the myocardium, and acute myocarditis may lead 
to a fatal termination. 

In addition to Weichselbaum's case autopsies have also 
been reported by Desnos, Schedler and Fleury. Desnos's case 
showed mitral and aortic insufficiency. In Fleury's case there 
was extensive destruction of two aortic leaflets. 



Blenorrhcea of the Sexual Organs. 315 

The prognosis, like that of ordinary acute endocarditis, is 
always grave. 

The treatment is similar to that of the ordinary form of the 
disease. 



III. BLENORRHAGIC EXANTHEMATA. 

In 1781 Selle said "that blenorrhagic pus maybe absorbed 
and give rise to cutaneous eruptions." This fact was subse- 
quently overlooked and the eruptions which appeared during 
gonorrhoea were attributed to the so frequently administered 
balsam of copaiba. In 1866 Pidoux again called attention to 
the possibility of the complication of blenorrhcea by cutaneous 
eruptions. I reported three cases in which blenorrhcea and 
cystitis were complicated by purpura rheumatica, in one of 
the cases also by pleurisy. In all three cases relapses of the 
blenorrhceic cystitis were followed by renewed swelling of the 
joints and purpura. Other writers have reported similar 
cases. In all the eruption belonged to the group of angioneu- 
roses, the various erythemata, both erythema multiforme and 
nodosum, urticaria and purpura, and occurred either alone or 
associated with rheumatism. The symptoms presented no 
differences from the well-known course, so that we will confine 
ourselves to these few remarks. 

Lang (1892) has recently observed an unique case which 
may be mentioned here. The patient, who suffered from 
urethrocystitis, was attacked by acute circumscribed suppura- 
tive dermatitis of the dorsum of the hand. Gonococci in the 
pus were demonstrated by the microscope and by cultures. 

IV. BLENORRHAGIC OPHTHALMIA. 

Apart from the primary diseases of the eye which are due 
to direct communication of the blenorrhagic virus, blenorrhcea 
may also be complicated by secondary diseases of the eye, 
which develop with or without rheumatism. These are char- 
acterized as blenorrhagic affections particularly by the fact 
that they always exhibit a tendency to recur on renewed in- 
fection. 

In the Reports of St. Bartholomew's Hospital (1852) are 
found a few cases of conjunctivitis and iritis which, together 
with rheumatism, complicated a blenorrhcea. Rollet described 



316 Blenorrhcea of the Sexual Organs. 

a blenorrhagic iritis. Guenan de Mussy reports the history 
of a young- man who, in two attacks of clap, suffered from 
rheumatism, conjunctivitis, iridochoroiditis and keratitis. 
Galezowski gives a detailed account of " iritis rheumatismale 
blenorrhagique." Koeninger reports the case of a young* man 
who suffered, during his first clap, from rheumatism, during 
the second from rheumatism and iritis, during the third clap 
from rheumatism and iridochorioiditis. Panas describes, under 
the term " keratite ponctuee," a form of iritis with deposits on 
the posterior wall of the cornea, which he claims to be a fre- 
quent complication of clap. Interesting cases are also reported 
by Schenkl, Haltenhof, Mengin, Kipp, Colsman and Seely. 

Blenorrhagic iritis, a quite rare affection, is usually asso- 
ciated with rheumatism as a complication of blenorrhcea. 
Among twenty-six cases collected by Jullien, three were com- 
bined with the monoarticular form, thirteen with the polyar- 
ticular form. The symptomatology is exactly like that of 
rheumatic iritis — discoloration and impaired mobility of the 
iris, contraction of the pupil, and distortion of the pupil in the 
rare cases of posterior synechia, photophobia, ciliary injection. 
The cornea presents a smoky opacity. On lateral illumination 
and examination with the opthalmoscope this opacity is found 
to consist of a series of opaque, whitish points, which are col- 
lected particularly in the lower half of the cornea, often in 
the shape of a triangle with the apex pointing upwards. The 
treatment does not differ from that of ordinary rheumatic iritis. 

V. BLENORRHAGIC ADENITIS. 

We have already discussed acute inflammation of the lym- 
phatics of the penis in acute urethritis of the male. A similar 
acute lymphangioitis occurs, although more rarely, in the 
female. The lymphatics which pass from the clitoris and labia 
minora at the inguinal region, swell into round painful cords, 
over which the skin is reddened. In some cases the inflamma- 
tion extends to the lymphatic glands, one of which, usually 
the nearest, swells into a painful nodule as large as a nut. It 
exhibits little tendency to suppuration, though this does take 
place in some cases. Bockhard found streptococcus pyogenes 
in the pus of such an acute suppurating adenitis, and it is 
therefore probable that we have to deal with a mixed infection. 



Blenorrhcea of the Sexual Organs. 3 1 7 

In other cases, in cachectic, scrofulous, tuberculous individ- 
uals, multiple swelling" of the glands occurs without symp- 
toms of acute inflammation and almost without pain. This 
leads to the development of large bundles of firm glands, which 
remain unchanged for a long time, bat are finally absorbed or 
undergo slow suppuration with the formation of fistulae. 

Finally, multiple painful swelling of the glands in both 
groins occurs in the beginning of very acute urethritis, but 
disappears with the acute stage of the primary disease. 

The treatment does not differ from that of acute and chronic 
buboes. 



3i8 



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Blenorrhcea of the 



Sexual Organs. 



319 



Differential 
Diagnosis of 



Chronic Anterior Urethritis, 



Superficial. 



Deep. 



Secretion at the ori- 
fice of the ure- 
thra. 



Test of the two 
beakers. 



Test of two beakers 
after irrigation of 
the pars anterior. 



Examination with 
urethrometer. 



Other characteris- 
tic symptoms. 



In more recent cases : muco- 
purulent secretion, constant- 
ly or as '•good-morning ,, drop. 
2. In inveterate cases : gluing 
of meatus, constantly or only 
in the morning, or meatus per- 
fectly dry. 

First portion slightly cloudy, or 
clear with clap shreds ; second 
portion clear without shreds. 



Both portions clear. 



No diminution 
of dilatability 



None. 



Chronic Posterior Urethritis. 



Superficial. 



Deep. 



No secretion at meatus. 
(N. B. — Any secretion which may be 
present comes from pars anterior 
and does not exclude posterior ure- 
thritis.) 



1. In more recent cases : First portion 
slightly turbid with clap shreds; 
second portion slightly cloudy with 
or without Fuerbringer's hooks. 2. 
In inveterate cases : First portion 
clear with clap shreds; second por- 
tion clear with or without Fuer- 
bringer's hooks. 

1. In more recent cases : First portion 
slightly cloudy with clap shreds ; 
second portion slightly cloudy with 
or without Fuerbringer's hooks. 
2. In inveterate cases: First portion 
clear with clap shreds; second por- 
tion clear with or without Fuerbring- 
er's hooks. 



Diminution of 
dilatability in 
one or more 
circumscribed 
spots. 

None. 



Increased or im- 
perative tenes- 
mus. Prostator- 
rhcea. 



Increased or im- 
perative tenes- 
mus, prostator- 
rhcea, micturi- 
tion or defecation 
spermatorrhoea, 
sexual irritative 
or paralytic 
symptoms : i n - 
creased desire, 
frequent pollu- 
tions, precipitate 
ejaculation, 
pain on ejacula- 
tion, feeble erec- 
tion, impotence, 
neurasthenia. 



ISDEX 



Abscesses, follicular and cavernous, 
215 

causes of, 219 

diagnosis of, 221 

prognosis and treatment of, 221 

symptoms of, 215 
Adenitis, blenorrhagic, 316 
Arthritis, blenorrhagic, 306 

Balanitis, 207 

adhesions of prepuce in, 211 

diagnosis and differential diag- 
nosis of, 212 

etiology of, 207 

phimosis in, 213 

symptoms of, 209 

treatment of, 214 
Bartholinitis, 293 

chronic, 295-297 

symptoms of, 294 

treatment of, 297 
Bladder, muscular apparatus of, 27, 
30 

inflammation of, 259 

sphincter of, 31, 36 

and urethra, differential diag- 
nosis of diseases of (tables) , 
318 
Blenorrhcea, complications of, in 
the male, 204 

extension to subjacent tissues, 
204 

gonococci the cause of, 205 

metastatic complications due 
to ptomaine intoxication, 207 
3l 



Blenorrboea, surface extension of, 

204 
Blenorrhcea in the female, 271 

complications of, 290 

diagnosis of, 275, 281 

forms of, 274 

frequency of, 273 

gonococci, importance of, in, 
276 

gravity of, 274 

latent, 272 

pathological anatomy of, 280 

prognosis of, 281 

symptoms of, 297 

treatment of, 282 

urethritis in, 297 
Blenorrhcea of the sexual organs, 
etiology of, 9 

history of, 1 

location of, in urethra, 45 

para-urethral, 51 

urethral, 23 

Chordee, in acute anterior urethri- 
tis, 58 
etiology of, 218 
spasmodic, 58 
venerea, 58 
Compressor urethras, 30 
Corpora cavernosa, chronic indura- 
tion of, 220 
Cowper's glands, inflammation of, 
222 
diagnosis and differential di- 



agnosis of, 



321 



322 



Index. 



Cowper's glands, perforation in 
acute, 224 

prognosis, 226 

symptoms, 223 

treatment, 226 
Cystitis, acute, 263 

chronic, 264 

diagnosis and differential di- 
agnosis of, 265 

etiology of, 260 

mucous, catarrhal, 263 

pathological anatomy of, 266 

posterior urethritis in, 259 

posterior urethro-cystitis in, 
259, 261 

prognosis of, 267 

purulent, 264 

treatment, 267 

Endocarditis, blenorrhagic, 312 

Endoscopes, 159 

Endoscopy, advantage of, 166 

technique of, 163 
Epididymitis, complications of, 245 
diagnosis of, 252 
disease of vas deferens in, 243, 

244 
infiltration and induration of 

epididymis in, 248 
pathogeny of, 239 
pathological anatomy of, 249 
prognosis of, 252 
relation of treatment of blen- 

orrhcea to, 239 
seminal changes in, 247 
symptoms of, 240 
terminations of, 246 
treatment of, 252 
varieties of, due to position of 
testis and epididymis, 237, 
244 
Exanthemata, blenorrhagic, 315 

Gonococci, as cause of complica- 
tions, 205 

characteristics of, 74 

importance of, in blenorrhagic 
disease in females, 176 



Gonococci, proliferation of, in con- 
nective tissue, 206 
resistance of epithelial tissues 
to immigration of, 205 

Hydrarthros, 307 

Induration, chronic, of corpora 

cavernosa, 220 
Infiltration, follicular and cavern- 
ous, 215 
causes of, 219 
diagnosis of, 221 
prognosis of, 221 
symptoms of, 215 
treatment of, 221 

Metritis, acute blenorrhagic, 297 
chronic blenorrhagic, 298 

Nephritis, blenorrhagic, 270 

Oophoritis, blenorrhagic, 300 
Ophthalmia, blenorrhagic, 315 

Perimetritis, acute, 300 

chronic, 300 

recurring, 300 
Periprostatic phlegmon, 231 
Phimosis in balanitis, 213 
Prostate gland, anatomy of, 28 

acute folliculitis of, 228 

congestions of, 228 

inflammation of, 226 
Prostatitis, 226 

acute, symptoms of, 227 

chronic, 232 

diagnosis of chronic, 233 

pathological anatomy of 
chronic, 232 

parenchymatous, 229 

periprostatic phlegmous in, 231 

prognosis of chronic, 233 

suppuration in, 230 

treatment of acute, 234, 235 
Pus cocci in complications of gon- 
orrhoea, 206 
Pyelitis, 270 



Index. 



323 



Rheumatism, gonorrhoeal, 302 

acute polyarticular, 307 

chronic, 308 

diagnosis and prognosis of, 311 

etiology of, 302 

pathological anatomy of, 309 

periarticular, 308 

site of, 304 

subacute, 307 

symptoms of, 304 

treatment of, 312 
Eussian clap, 57 

Salpingitis, 300 

Seminal vesicles, inflammation of, 

258 
Spasm of urethra, 37 
Spasmodic chordee, 58 
Spermocystitis, acute, symptoms of, 
258 
chronic, symptoms of, 258 
Strictures in chronic urethritis, 144 
Suspensories in acute urethritis, 95 
Syringes, urethral, 106, 114 

Tendo-vaginitis, blenorrhagic, 308 
Thompson's test for location of 
urethritis, 53 

Urethra and bladder, differential 
diagnosis of diseases of 
(tables), 318 
calibre of, 24 
dilatability of, 25 
divisions of, 27 
measurements of, 27 
muscular apparatus of, 27 
spasm of, 37 
Urethral blenorrhoea, 23 

anatomical and physiological 
remarks on, 23 
Urethritis, diagnosis and differen- 
tial diagnosis of, 73 
Urethritis, acute, 41 
anatomy of, 81 
infection, modes of, 41 
instrumental remedies in, 105 
prophylaxis of, 92 



Urethritis, symptoms of, 45 

treatment of, 90, 97, 118 
Urethritis, acute anterior, 46 

chordee in, 58 

course of, 59 

disturbances of discharge of 
urine and semen in, 58 

florid stage of, 49 

general symptoms of, 59 

inflammatory symptoms in, 50 

period of incubation, 46 

prodromal stage, 48 

prognosis of, 79 

relative frequency of, 65 

secretion in, 52 

sexual irritative symptoms of, 
56 

subjective symptoms of, 56 

treatment of, 119 
Urethritis, acute posterior, 62, 259 

albuminuria in, 71 

anatomy of, 81 

course of, 73 

forms of, 72 

general symptoms of : 72 

period of development of, 64 

prognosis of, 79 

relative frequency of, 65 

secretion in, 70 

sexual irritative symptoms in, 
70 

symptoms of, 66, 70 

treatment of, 133, 137 
Urethritis, chronic, 138 

anatomo-pathological changes 
in, 171, 175, 179 

diagnosis and differential di- 
agnosis of, 181 

dilatation in, 192, 200 

etiology of, 138 

forms of, 194 

gonococci in, 150 

infectiousness of, 154 

localization of, 155 

pathological anatomy of, 169 

phosphaturia in, 187 

prognosis of, 188 

secretion in, 149 



324 



Index. 



Urethritis, symptoms of, 141 

treatment, 189 
Urethritis, chronic anterior, 143 

strictures in, 144 
Urethritis, chronic posterior, 145 
Urethrometers, 26 
Urethrotomes, 192 
Uterus and appendages, inflamma- 
tion of, 297 
Urogenital diaphragm, 29 



Vaginitis, 282 

diagnosis and prognosis of, 285 

symptoms of, 283 

treatment of, 286 
Vas deferens, disease of, in epidi- 
dymitis, 243, 244 
Vulvitis, 290 

diagnosis of, 292 

symptoms of, 290 

treatment of, 292 




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